HomeMy WebLinkAboutRetreat Center - BLD Application - 4/1/1999 09 : 36A Rice Fergus Architects 360 792- 1385 P _ 03
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MUST Be ComftETED W INK PERMIT NO: BLD
.Se PRESS HARD MASON COUNTY
BUILDING PERMIT APPLICATION
428 W.CedarrP.O_Box 196,Shafton,WA 915"
ShNton 1E0 27-9970 8slfair 1Q0 275Id67 EbrW i0 Y2-6269 Seattle 00 b96E
APPLICANT INFORMATION CONTRACTOR INFORMATION
Ownor ESE OL- Contractor Name G10 NTWI T 11 sl"�
Mailing Address 1 /'w Mailing Address
city �jlEA"j11 State ,Zip Code 981t2 City State Zip Code
Phone( Other Ph (� Ph j ) 011)er Ph.( )
L,en[Title Holder Contractor Reg. tl
Adaress Expiration
SEPTICIWATER SYSTEM INFORMATION-Connect to New Septic Exist- Septic Can to Sewer
System Name of Sewer System WellWater System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No f o 000 Fire District
Legal Description
Site Address(Please Include street name, street number and city) p
Directions to site,-P—SN_E _ 5T o e o
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water (Name) 4A0&r> C'Aq'�L Sahwater _
Ldke Rlver/Creek_ Pond Wetland Seasonal Runoff Stream Slopes or
Blues
TYPE OF JOB Nttw A.dd Alt_•k_Repair Other Use of building 1- GQJrF�
Describe Work I Tlo& 4 i'Z 1,4• FT. 0bE 577,
No of BedroomslLg�i_No. of Bathroct nsk_SQUARE FOOTAGE-1st Floor In nd Floor 20
3rd Floor ____Lott Basement Deck Other ffv 630 + T
Gara a ---Attached =--0etached ---Carport — I Attached--Detached
MOBILE HOME INFORMATIOAL Make Nk Model N Ac-- Model Year Nit
LeNthth�C_Width t4A-_Serial No, No. of Eiedraoms-Wjl�7- No, of Bathrooms
Type of Heat N4'c' Purchase Price N.111l Replacement Unit 7(Yes/No)
Installer Name Certification No,
NOTICE: THIS PERMIT 6FtOMES NULL&VOtp IF WORK OR COµSTRUCTtON AtJTF CHWED IS NOT COMMENCED WfTH N 110 DAYS OR IF
GONE TRUCTiON WORK LS SUSPENDED OR A MDM&D FOR A PERIOD OF 180 DAYS AT ANY TIME AFTFR THE WORX IS COMMENCED,
PROOF OP CONTINUATION OF VIIORK IS HY M Aµ$OF A PROGRESS INSPEC'TDON. The owner or agent out owners befraff,reprosanta trot t11e
infort7u0on provided is accurate and prarrta amployses of Mason County access to trte above descrfbed p+vp.rty and raructures for review and
tnapection of this protact Atknou.hdgrnent of such is by slgnaWre betovr.
OWNER AFFtOAVJT-1 cerVy that I am eaempl kom&a re4uharr*m2 of the CONTRACTOR'S AFFtL1AVIT-1 terrify tlyt I am ameruJy raBlstared ab a
CantteCW Registration Law R C W 10.27 and am arras or Uw ordum%cr cwft-* or In the state of WaN w%fion and that I am wwMe of the ordmanca
teQuire ner4><far whti tttia peamR 1s iseLad vid Met a0 cork vrbl he done in reaukWrdwd2 teguta"the t+ravll for vAnch&we psrrrtt is maued and a1 work
caNananc o thw wW No crwrly-s14011 bar rn9de wOKLA feat obtaining shag be dune m wnt anw%ne 0nrewrth. No changes sAss be made r.ithout
app oval rbK o ty appro010,
X Dale X Dato
FOR OFRCIAL USE BEYOND THIS POINT
Accepred by�--Date—Submittal Amount pue Receipt No.