HomeMy WebLinkAboutMIS95-00498 Foundation - MIS Application - 7/13/1995 0.,00
rmit No.
MASON COUNTY
(� 1DING PERMIT APPLICATIONP
�426 VW ei dar/P.O. Box 186 Shelton WA 98584 427-9670/1-800-562-5628 m 1'7 r o9`18
PLEASE PRINT
#1 wner �h s by Phone#s3� 7
U '2, 9- SYS(�
Ite Address /l/� /�/3/ �o//iss �g��1�r�. Fire District# �
City �q��„� St W,4 Zip S-8
Directions to Job Site n//4,r �E
Owner Mailing Address_ ���j/�'
City St Zip —
Lien/Title Holder �--
Address �S_�O S ��c�cawG v n ��✓
Clty St U/.f Zip 9ffo?i!
#2 Contractor Name 9.c Contractor Reg
Address T71Z- e Expiration Date S-'/ /5�
City St (it//t Zip Phone# j;�d -4 9 SSA 7
#3 If septic is located on project site, include records.
Connect to Septic? Public Water Su DI ell
Connect to Sewer Systems ame of System
(If residenti of potable water is required)
#4
#5 Building Square Footage: (existing/proposed)
1st FI / / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other sq.ft. /
#6 Use of building o r Describe work
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION MR@R9TN [@
Model Year Make
Length Width Serial No. J U L 12
iM
# Bedrooms #Bathrooms Type of Heat
Purch rice$
HEALTH SERVICES
#9 Indicate by circling the applicable source if an water is on or adjacent to subject property:
Lake
River Pond Creek Stream Wetland )Marsh Saltwater Seasonal Runoff Other
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Driveways
Water Lines Shorelines
Drainage Plan Topography
Septic Systems Wells
Proposed Improvements Easements
Name of Flanking Street Indicate Directional by (N, S, E, W)
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each) 1
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
Bath Basins Heatpump, Other
th Tubs No. nits Fees
Sho ers Furn BTU
Hot W er Htr Heatpumps
Laundry asher — Vent Systems
Sinks pot Vent Fans
Floor Drains No. B 'I rs/C m r
Laundry Basins —
Dishwasher No. Air H n lin Units/
Disposal _ cfm#
Urinals No. Fire Protecti n&stems
Other Auto. Fire A r Sys 50.00
Fixed Fir Supp. ys 50.00
Perm' Basic Fee 15. Auto Fir Sprink Sy 25.00
T TAL PLUMBING $ No. h r
_ Ga Outlets
ood, Gas, Pellet Stove
NOTICE: THIS PERMIT BECOMES NULL AND VOID IF
WORK OR CONSTRUCTION AUTHORIZED IS NOT COM-
MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Per it Basic Fee 15.00
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD
OF 180 DAYS AT ANY TIME AFTER WORK IS COM-
MENCED. PROOF OF CONTINUATION OF WORK IS BY
MEANS OF A PROGRESS INSPECTION.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED
MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AM AWARE OF THE ORDINANCE REQUIREMENTS REGU-
ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED
MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE
CONFORMANCE THEREWITH. NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT
MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTMENT.
X OWNER X BY
DATE DATE
j
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning: �10 '-se 6yaro Ii ko- x /f� SiC/� ��GaY'� Avy
Environmental Health: _- �1� � �, 1�-'� SGGi)n c, /� A
Uv v�
Building Plan Review
N
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit M S
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other_r
Other
Building Valuation: TOTAL FEE 5—l"