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MASON COUNTY PERMI�NO
BUILDING PERMIT APPLICATION
_;t 426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 • Belfair(360) 275-4467 Elma (360) 482-5269
I IC I' On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Company Name
Mailing Address 'T f c,l 4xp,c t- , y3ka s pra Mailing Address
City M- .15L State '-JA Zip Code 99%5'Lk City State Z' 'Cod
Phone 3(,o-Z75-0(q,63 Other Ph. Phone `tither Ph. —
Lien/Title Holder Contractor Reg. # Expt
j E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic St
Connect to Water System Name of Water System
Well Sewer Systern Name of Sewer System
PARCEL INFORMATION -.12 Digit Parcel No. Fire District
Legal Description t l ;- .. t....{. I t
Site Address(Please include street name, street number and city)
Directions to site S R 3, 'TO �', n-a,4-t M p ,
Ga T vtr-r7r -.SF�
0 4 '
Will timber be cut and sold in parcel preparation?Yes
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_)L_Alt Repair Other PRIMARY RESIDENCE 2 SEASONAL ❑
Use of Building sszit.. Describe Work-14-44 i$ Nov rT,o..► Val -'T> G.dc,,.
No. of Bedrooms No. of Bathroom19 Square Footage- 1st Floor I U 51 2nd Floor
3rd Floor Basement Deck V 5' Covered Deck L L'_Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOFORMATION - Make Model Year
Length Widt Serial No. No. of Bedrooms athrooms
I
Type of Heat Purchase P $'� Replacement es/No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation. I
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 obtained permission from them to apply for this permit and conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the above
described property and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANS OFAPROGRESS INSPECTIO INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION.
X '� A G Date: !Y/ / 7 Owner Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYON . Pb - Accepted by: _ ' '! 1 Date
DEPARTMENTAL REVIEW ,A O1VEbI DENIED NOTES
Building Department
Planning Department
Environmental Health Department
Fire Marshal
FEES I Building Permit Fee Site Inspection i Plan Review Fee 6 EH Review Fee
Plumbing & Base Fee 4° Planning Review Fee
Mechanical & Base fee 3° O Other
Wood/Gas/ Pellet Stove Fee r State Fee i
Violation Fee Pre-Paid at Submittal
Valuation $ <64 Z 7 TOTAL FEES
a
ME
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY PERMIT NO.
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar•P.O. Box 186, Shelton,WA 98584
Shelton (360)427-r70•Belfair(360) 275-4467•Elma(360) 482-5269
n the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner 3 _ g �1 T3�cc 1A k- may
Company Name
Mailing Address - o�y� p rc 'Pats sis�vri D n Mailing Address
City 13 c1eenny'- State IAJ h Zip Code 98sZ$ City Mate ZipCode
Phone'340-z'7S-0to63 Other Ph.
Phone Other Ph.
Lien/Title Holder Contractor Reg.4 Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION- 12 Digit Parcel No. Fire District
Legal Description
Site Address (Please include street name, street number and city)
Directions to site
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
TYPE OF JOB - New Add Alt Repair Other Use of Building
Location of Fixtures/Units - 1 st Floor 2nd Floor Basement Garage-Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric X— LPCz_ Natural Gas— Heat Pump_
Toilets I Tvpe of Unit No. of Units Fees r
Bathroom Sink -z Furnace I i
Bath Tubs I Heatpumps
Showers Spot Vent Fan
Water Heater I Propane Tank i
Clothes Washer Gas Outlets
Kithen Sinks Wood/Gas/PelletStove j
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee I
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/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 obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROrF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Date:- Tj b 07
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
i
Occ Group—Tyge Constr.—
IlPlanning Department
Environmental Health Department
FEES
TPlumbina& Base Fee Site Inspection
echanical&Base fee UFC Plan Review Fee
od/Gas/Pellet Stove Fee Other
lation Fee TOTAL FEES