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Ap Mail#ig Address ► Cit�r ' Zip Cod City State / zip Code Phone i her Ph.O Ph. 88 Other Ph.. Pr Lien/T tle Holder Contractor R # Address Expiition ' ►/41xCEL fNFO }. 2 di 't Tax ParreY: ie 1.3.E 3 2«:: / 1 j- 1 'l-.v f' District °Legal Descri0on� I 2- Site ddress(inClude street name and cityZOA AN DiActions to site: f ill timber be cut and sold in pa el preparation? (Yes/No) Is your property within 200' of the following: Body of Water(Name) 14 Sa 2%he VSaltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs 2 TYPE OF JOB New Add Alt Repair Other Use of Building Describe proposed construction SHORELINE,PROJECTS New Replacement Repair Expansion Bulkhead Material.(concret oc ood, etc.) Length /tr: Height C A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT- No.TiOE: THIS PERMIT*ECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COM LACED WITHIN 1$0 PAYS OR IF CONSTRUCTION WORK'J,,S SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF,GONM1*- I OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the information provided is adfurate and grants employeesof Mason County access to the above described property and str4ctures for review and Inspection of this project.Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a the Contractor Registration Lark RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the ordinance.Iequirements for whiff h this permit is issued qnd that all work ordinance requirements regulating the work for which this permit is issued will-be done in conformance therewith. No changes sha#,be made without and all work shall be done in conformance therewith. No changes shall first obtaining approval. be made without first obtaining approval. j X u Date X Date ! FOR OFFICIAL USE BEYOND THIS POINT Accepted by V�,0 > Date/Submittal Amount Due ,. Receipt No. DEPARTMENTAL R IEW nrPROVED DEwE�z CONDITION CODES Building Department Occ Grp, Type of Const. Planning Department Environmental Health Department Public Works Department Fire Marshal Valuation$ , , `;% FEES Building P60nit Fee SO-inspection Plan Review Fee Other UFC Plan Review Fee y Other Violation Fee Pre-Paid at Submittal - ( , ) r TOTAL FEES PERMIT NO.: MIS -1-C),51 ASON C� oz 7 a3 ' MISCELLANEOUS PERNOTAPPLICATION 426 Vet.;CedaNP.0.Box 186,Shelton;.WA 88584 Shelton M 27-9670 Ma_fr OPJ275-4467E =6289 Seattle 206 4968 APPLICANT INFO NATION CONTRACTOR INFORMATION owner dwractor Name .;✓ r.400.l _ Mailing, ddress Maitihgl Address k City eta#e Zip Code City »r State,Aim Zip Code ft-C-IQ PhonnA her Ph.(z 6 ) = Ph. as Other Ph. -- LieNTiti�Holder Contractar.Reg.#�i' A d2Ud Address Expiration / / !d PARCEL INFO TION-12 digit Tax Parcel No,. �.7-'S �-• / _/ 9 �-1 Fire District Legal Description Site Address(include street name and city Directions to site: a ,� T? 'T' ,�.a/sJ7.►11 _��,tl �trit���r 41A Will timber be cut and sold in pa el preparation? (Yes/No)Aa Is your property within 200'of the following: Body of Water(Name) _ sE' 1.+�tf" Saltwater/^ -Lake River/Creek Pond-Wetland Seasonal Runoff Stream Slopes or Bluffs FFYPE OF JOB New Add Alt Repair Other Use of Boikt ng Describe proposed construction &A,. �rrs ii.. ,�10��fc .►l�l tt.� SHORELINE PROJECTS New Replacement Repair X Expansion Bulkhead Material,(c;oncret ck dod,etc.) Length L43" Heiot A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT.,, i, NOTICE: THIS PERMIT COMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS.OR IF CONSTRUCTION WORK' SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER f0it WORK IS COMMENCE. PROOP'OF,,CONTIIWA OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the infotl obon,provided is a urate and grants employees of Mason County access to the above described property and strictures for review and Inspection of this project. cknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify at I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT4 certify that I am currently registered as a the Contractor Registration RCW 18.27 and am aware of the contractor in the State of Washington and that 1 am aware of the, r ordinancg requirements for this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued will be done in conformance tiie�ewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall first obtaining approval. be made without first obtaini approval. X Date X Date " 7 7 F R OFFICIAL USE BEYOND THIS POINT Accepted by ate'%ji-J Submittal Amount Due .3 Receipt No. `J DEPARTMENTAL R IEW oQaEo CONDITION CODES Building Department 'L 3f7 Occ G T of Cont. if Sw SZ Planning Department Environmental Health Departrrtent Public Works Department Fire Marshal eep, 3?.,5-sFX . so Valuation $ Q 1 w*: FEES Building Permit Fee S'6lnspection Plan Review Fee ,.F Other. r UFC Plan Review Fee Other N Violation Fee Pre-Paid at Submittal� 54 ) + TOTAL FEES ��