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Se backs Date B y Ribbons rn Date 1 ( � ( By Gas Piping Date B o Foundation alls Date By Set-up Date By INSULATION Date By B G I Slab Insulation Floors Final Date By Date By Date By FRAMINGC'�`� i Walls FIRE DEPT Date B y _� ` Date B y Date B y PLUMBI G Attic OTHER Groundwork Date By Date By WALLBOARD NAILING D N.V. Date By Date By FINAL NS ECTION Water Line Date By L` Date By Date By CD a CD CD C a 0 r x d o � 8 � 0 0 0 O � J H 0 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT N0.P) D,2C1- PLEASE PRESS HARD BUILDING PERMIT APPLICATION 426 W. Cedar• P.O. Box 186, Shelton,WA 98584 Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma (360) 482-5269 On the web www.co.mason.wa.us APPLICA TIN OR TION CONTRACTOR INFORMATION Owner Company Name Mailing Address Mailing Address Ci State WA Zip Code T City S ZipCode Phone = v Other Ph��. 0127 Other— *ygr Phone Ph. Lien/Title Holder Contractor Re . Exp. E mail address E Mail Ad ss Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No. ®©Ov Fire District Legal Description * Site Address (Please incl de street name, street qumber qnd cit Directions to site Will timber be cut and sold in parcel preparation?Yes/ o Is property within 200'of Saltwater _Lake River/Creek Pond Ad Wetland Seasonal Runoff Stream _Slopes or Bluffs J 15% X& Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add-X—Alt Repair Other IIMARY RfESIDENCE X SEASONAL ❑ Use of Building Describe Work' No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No.of Bedrooms No.of Bathrooms Type of Heat Purchase Price Replacement Unit? Yes/No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or Acknowledgement of Y p permit revocation.Acknowl such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents itlb r�1labon provided is accurate and grants employees of Mason County access to the above described property and structure for revs t PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X �.�✓. Date: �® —/—05� Owner/Owners Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: CFUAR DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department i Environmental Health Departmen Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee Planning Review Fee Mechanical& Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES MASON COUNTY PERMIT NO. .: , BUILDING.PERMITP. ox 6APPoLICAT,WA8 O584 N426 W.Cedar — Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma (360) 482-5269 On the web www.co.mason.wa.us APPLICANT INFORM TION CONTRACTOR INFORMATION Owner Company Name Mailing Address Mailing Address .� City State WA Zip Code fZ6;L7 _ City St Zip Code Phone Other Ph.4 W4)121r_ z= Phone Other Ph. Lien/Title Holder Sa4moe Contractor Re Exp. E mail address E Mail Ad ss Drivers Lic.# DOB Drivers tic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Sep#ic Existing Septic Connect to Water SyIS'fem _ ____Name of water System— Well—Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No.i 2 ,2 193 3'mop© Fire District Legal Description * . 1041 Site Address (Please include street name, street number and city) �" Directions to site p� - 4*1ac_s'daz ri, 1 s �r -- � Will timber be cut and sold in parcel preparation?Yes/ o Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Al.& Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repair Other PRIMARY R SIDENCE SEASONAL ❑ Use of Building Describe Work No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Gara a Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No.of Bedrooms No.of Bathrooms Type of Heat Purchase Price$ Replacement Unit? Yes/No Installer Name Certification No. CMMER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If pe . ion is required from any easement holder or any other party in interest regarding this application or the work proposed in the apl permission from them to apply for this permit and conduct the work proposed. The owner-or agent on owners behalf,rep i tion provided is accurate and grants employees of Mason County access to the above described property and structure for review and i pp 4 PROOF OF CONTINUATION OF WO IS BY MEANS OF A PROGRESS INSPECTION. �C I o 1J1J X Date: /© —/--G?4( 1 Owner/Owners Representative/Contractor indicate which one CEDAR ST1. FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Departmen Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing& Base Fee Planning Review Fee Mechanical&Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee' Pre-Paid at Submittal Valuation$ TOTAL FEES MASON COUNTY PERMIT NO. ,�;Aa-J I€ P` WILDING PERMIT APPLICATION 426 W.Cedar• P.O. Box 186, Shelton, WA 98584 Shelton (360) 427-9670• Belfair (360) 275-4467• Elma (360) 482-5269 On the web www.co.mason.wa.us lAPPLICA T IN OR ATION CONTRACTOR INFORMATION Owner Company Name Mailing Address Mailing Address CityJuadAd _ State WA Zip Code City St Zip Code_ Phone Other Ph(jQ)2-7jrr5 j X Phone Other Ph. Lien/Title Hold er sadmic Contractor R Exp. E mail address E Mail Ad ss Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSI TAM INFORMATION - Connect to New Septic Existing Septic Connect to Water Sy§Gt '_"e Name of Water System-- Well-Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No. Fire District Legal Description N A Site Address (Please incl de street name, street number and city) M Directions to site 2:d cl.-� lY � Will timber be cut and sold in parcel preparation?Yes/� o Is property within 200'of Saltwater ,Lake River/Creek _Pond_. _ Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repair Other P IMARY R SIDENCE §Q SEASONAL Use of Building Describe Work No.of Bedrooms No.of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial.No. No.of Bedrooms No.of Bathrooms Type of Heat Purchase Price Replacement Unit? Yes/No Installer Name Certification No. OMVER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,rep Led don provided is accurate and grants employees of Mason County access to the above described property and structure for PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X—�1 �f- c.r''r�� Date: le —/-04t OCT U 7 2004l Owner/Owners Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: 42�a DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department /o _ Planning Department Environmental Health Departmen Public Works Department Fire Marshal FEES o Building Permit Fee Site Inspection Plan Review Fee S�. l EH Review Fee Plumbing &Base Fee Plannina Review Fee Mechanical& Base fee Other Wo [Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation$ 0 TOTAL FEES ',:- , f