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Home My WebLink AboutBLD2007-01988 Dock - BLD Application - 1/11/2007 FORM MUST BE COMPLETED IN NK MASON COUNTY PERMIT NO.6 1 ' V 145 PLEASE PRESS HARD 91JILDING PERMIT APPLICATION C� tv�- - 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 APPLICANT INFORMATION CONTRACTOR INfOP,.MATION Owner (' -f- -Cep Pe,-,LerSepj Company Name "A:i'S40rr, C9n .4- Mailin Address77_ A/E 7;4,e/ 174 a 0 U/ Mailing Address4q0'X'-0SW- city--- ifi I- State_" Zip Code 9R S28' City8e,/441-11 State L44 Zip Code Phone(0nhK-'fT_""K "--Other Ph.36o2�'SS Phone O S ?s7 Other Ph. Lien/Title Holder Contractor Reg. e r t1 1.4 Exp. _og E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic X Connec to Water System Name of Water System Well Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. D - - o a Fire District Legal Description"Tje )7% o,C Gorr;- 404 Z PCL_ 2 o-F R)A Site Address (Please include st eet name, street number and city Directions to site o yr Ark 7 / f Will tuber 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 o TYPE OF JOB - New_Add Alt Repair Othef PRIMARY RESIDENCE R SEASONAL ❑ Use of Building Describe Work e r4e�2ty Nr,< No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. 34e— 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 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. 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 OF RO�7SPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: -/ -0 7 Owne Owners Representative/ ontractor indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee Planninq 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.j i BUILDING PERMIT APPLICATION l� +� 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 APPLICANT INFORMATION CONTRACTOR IN ORMATION Owner -1+ )ark-rerr PC 4 r/gt'`./ Company Name Mailin dress7_10 AIL 77' r 1<16� A ta*// Mailing Address p�- City ¢' fuZ _State LLAO Zip Code !2 q ,: '1* City> / ra, -c State ike+ Zip Code i'�.'SeA Phone( f. * 1102`h -----Other Ph.`?,40%�5 -��2� Phone Other Ph. Lien/Title Holder Contractor Reg. "d.3J4 Exp. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic 2< Connecto Water System Name of Water System Well d Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. J 2 1 P -• 2L. 00.130 Fire District Legal Description 6,9�U �-v r t- 204 Site Address(Please include street name, street number and city) v ` �'' ti Directions to site ,, � . ; f.:� = r• 14.1 r:J 4 / �v z. '� s: 14 1 :V iv e a2 C., / �I Will timber be cut and sold in parcel preparation''Yes `o a 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?Yesl_0D TYPE OF JOB - New '< Add Alt Repair Other PRIMARY RESIDENCE 5? SEASONAL ❑ Use of Building Describe Work ,�, y-r All ' ' �' / No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other / z Sq. ft. ,i6eQ 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 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. 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 OFArPROGRES S NSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X f2r. i ,,-. M Date: f '"? ownelef Owners Representative/Contractor (indicate which one) i FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW AP ROVED DF,,NIED NOTES Building Department Planning Department Environmental Health Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee Z•3 EH Review Fee Plumbing & Base Fee ^ Planninq 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 N f BUILDING PERMIT APPLICATIO14 �� ti�,h• 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 APPLICANT INFORMATION CONTRACTOR INFORMATION Owne Company Name,/ „ �_c4RE; r•�..��- Mailing Ad rest g �; � 1 1 1 Mailing Addres0��w W.Cg' City _Ie . Stated—Zip Code T gs�.�.2,g' —. C ej& State_ Zip Cod Phor�.� ther Ph�� _ PhonF1 7� _T' Other Ph. Lien/Title Holder Contractor R ---.rA _Exp. E mail address _ E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic a Connect to Water System Name of Water System Well NC ,Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel Noj,7-2 nc:- 2/- do 4:3 0 Fire District Legal Descriptiort4!�e G 9c _ c• IT�TG t�rers-�-,� a•��1-��---�a�-�y4--�� 2 I Site Address (Please include street name, street number and city) Directions to site ' it imber be cut and sold n parcel preparation?Ye 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?Y TYPE OF JOB - New>(- Add Alt Repair Other PRIMARY RESIDENCR;71 SEASONAL ❑ Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square f ootage- 1st loon 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 Pub haSe Price $ A Replacement Unit? Yes/ No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inac�,urate"in formation 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 cl&fhe work as,proposed in the application. I declare that I have obtained the permission from all the necessary parties. If permission is:req`tjixedifrom ark easement holder or any other party in interest regarding this application or the work proposed in the application, I have obtained perrrfission 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 OF PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: �/�'? wne Owners Representative ontractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by. v Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department o D 8 a Environmental Health 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