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Permit No.&M-0205
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton,WA 98584 427-9670
(Calling From: Seattle 464-6968, Belfair 275-4467, Elma 482-5269)
PLEASE PRINT
#1 Owpdr XO r\ft 6 1 C�' 0_nSv ro PhoneJ 01
ite Address Fire District# �
ity St_(Lh_ Zip
Directions to Job Site -Tt,Y, vJv�1' o
v V✓� ,` ti 0 ,lA
'l 4 4
_ Owner Mailing Address �AQC��. C 0r d
J
City V\'A St Zip
Lien/Title Holder 0&j/U� Q _
Address
City St Zip
#2 4Contractor Name 3U UJ.Cyr 5 �'f`'� C�YT 71<�BI # LU,,*C 5 a1 S
Address ontractor Reg #
City �o\f/q ho P St v) A Zip Phone g��� piratio /
#3 If septic is located on project site, include records.
Connect to Septic? Public Water Supply ✓ Well
Connect to Sewer S tem? Name of System
(If residential, proof of potable water is required)
#4 el No
( Legal Description r-2-e C1 b<-> 1�. I �T 1 L Y" 16
#5 Building Square Footage:
1st FI_ �2— 2nd FI 3rd FI Loft Basement
# Bedrooms #bathrooms Deck Other
Garage Carport (Circle: Attached or Detached?)
#6 Use of building �G ' �1 Lt Describe work
#7 Type of Job: New Add Alt Repair Other
ar
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year 3i Make Model C 14 Y 16 va-FCK
Length Width I q Serial No. 5 D )-S9
# Bedrooms aZ # Bathrooms I Type of Heat
Purchase Price$ I goo
#9 Indicate by circling the applicable source if any water is on or adjacent to subject property:
River Pond reek Stream Wetland Lake Marsh Saltwater Seasonal Runoff Other
Show following on the site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Drainage Plan Wells
Septic Systems Easements
Proposed Improvements Indicate Directional b N, S, E,
Name of Side Street y ( W)
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
zS
14
1,
J v�
rZIN CA
C-4
i"
G �
t
APPLICANT TO DRAW TOPOGRAPHY PROFtE BELOW
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C
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so "
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review �fc 3� 1 ,a x
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other S
Other
Other
Building Valuation: TOTAL FEE
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plaq Review 3 -1
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
00
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other
Other
Other
Building Valuation: TOTAL FEE
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review 3� �a x
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other
Other
Other
Building Valuation: TOTAL FEE