HomeMy WebLinkAboutCOM2003-00041 Repair HQ Carports 1 and 2 - COM Application - 1/16/2004 L PERMIT NO.: BLI.
GUN TY Co M ZDO-3—
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275A467 Elma 360)482-5269 Seattle 206 464-6968
APPLIC NT INFORMATION CONTRACTQR INFORMATION
u L` 1 , 01
n C,, ` Contractor Name'
Owner S,� try Mailing Address / QW,
Mailing Address(.d00 (��QQ�-►U a�'� / �. k� (��D p I'St�te lam_ Zip Code 'IOU t
{�Q� m �-f0l'► State �t ZipCode 9���? City
City,;, - �- Ph.L3AzQ Other Ph.c 53 )fib I-0308
Phone(3_bo) U7 Other Ph.( ) l.J `trF
Contractor Reg. # O
Lien/Title Holder Expiration O 1
Address
Connect to Sewer
'SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic EWelling SeWater System Name of
System Name of Sewer System
Water System
#f
/ / Fire District
PARCEL INFORMATION-12 digit Tax Parcel No.
Legal Description
Site Address(Please include street name, street number and city)
Directions to site
Will timber be cut and sold.in-parcel preparation? (Yes/No) 11 O� G N j� Saltwater 7�►
Is your property within 200' of the following: Body of Water(Name) t'l Slo es or
Lake River/Creek Pond Wetland Seasonal Runoff Stream P
Bluffs
PERMANENT RESIDENCE ElSEASONAL RESIDENCE❑
TYPE OF JOB N Add Alt Repair Other R Use of Building '
Describe,Work nb��ervr
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor sq ft.
Loft Basement Deck Other }
Nor.
Attached Detached
Garage Attached Detached Carport
Model Model Year
MOBILE HOME INFORMATION-Make No. of Bedrooms No. of Bathrooms
Length Width _Serial No.
Purchase Price $ Replacement Unit ?(Yes/No)
Type of Heat Certification NO. +.
Installer NameOT COMMENCED WITHIN 180 DAYS OR,
AUTHORIZED IS N
N the "i
OTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION
180 DAYS AT ANY TIME AFTER THE WORK IS OOAICIVI NCED!F
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIODheownbr or agent on own
PROOF OF CONTINUATION OF WO dK�a BY
emEptoyeeANS Os of MasF A OonRCounty accessESS Oto the abave described property and structures lures for review tand
information provided is accurate g wi
inspection of this project. Acknowledgment of such is by signature below:
y that I am
OWNER AFFIDAVIT-I certify that I am exempt from the requiremen ts of the CONTRACTOR'S actorn theSta e o Washington and and that am awarle of tthe orrdi ance
is,issued and all work
Contractor.Registration Law RCW 18.27 and am aware of the ordinancefor
requirements for Which this permit is issued and that all work will be done in requirements shall be done in conformance olnfo mance therewith.cNohchanges shall be made wi hout
conformance therewith. No changes shall be made without first obtaining first obtaining approval.
approval.
Data
X Date
FOR OFFICIAL USE BEYOND THIS POINT
Receipt No
Accepted by
Date Submittal Amount Due P
;.
ApPR,C?VED ; pNi,I»Q..
CONDITi� COi-
NT.A. R. 000
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Building Depa ent y
Occ Grou Toe Constr.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation7777
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Site Inspection
Building Permit Fee s,;
EH Review Fee
Plan Review Fee
Plumbing
Review Fee
&Base Fee
Other
Mechanical&Base Fee
State Fee
Wood/Gas/Pellet Stove Fee
Pre-Paid at Submittal ( ``
Violation Fee
TOTALFEES
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