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[w. Q PERMIT NO.: BLD
MASON COUNTY
BUILDING PERMIT APPLICATION
AM W.Cedar/P.O.Box 186,Shelton,WA 99504
Shelton 360 427-9670 Belfair 360 275-4467 Elma 60 82.5269 Seattl 06 64-6968
AFPIL IN QRMATION CON'1"RACTOR INFORMA ICON
Owner 7 'v Ck A Contractor Name 5 c sr� C'dAc,51"c io.w I
Ma)Ii g Address '} gib... X Mailing re
i
Cite it3 v i O W State " Zip Code Cit �e rra z' State ! Zip Code 9 S'
Phone( ) , Other Ph,( ) Ph. 6,o . `7— 'Other Ph. : (-o Sew-�y3
` Lien/Title Holder !M E Contractor Re #C e o L1"sJocWQ2&/p Y �
C Address Expiration 0 /Z Lzp,.0
I
i SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic, Existing Septic Connect to Sewer
System Name of Sewer System Well Water System Name of
Water System I
PARCEL INFORMATIQN-12 digit Ta Parcel No. Z/, IS7 / t`a -010 Fire'Districty$`""`
Legal Description V14 IndD
Site Address(Please include 9treet name, street number'and city)
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No) A4/0
Is your property within 200' of the following: Body of Water{Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Sloks or
Bluffs
1TYPE OF JOB New Add It rRepa' Aoo'' Other Use o Buildi
Describe Work 4F
No, of Bedrooms No. of athroo s SQUAIkE FOOTAGE-1st Floor 2nd Floo _
3rd Floor Loft Basement a4ck_�,_Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model _' Model Year
Length Width Serial No. No ofi BedroomsNo of Bathrooms
Type of Heat Purchase,Price $ Replacement Untt`'?(Yel�}
Installer Name Certification Np.
-NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 1"DAYS IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIMEAFTER THE WORK is COMMENC D.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-,I certify that I am currently registered as a
f Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washidgton and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approvaC first obtaini approval
I X
///
X Date X y� % Date
FOR OF ICIALUS ND'BEYOTHIS OINT
. . r
Accepted by Dat _ mittal Amount Due Receipt NHS
,:::.<::a:::::.:
..... ..........:...::: �a .E�I„ #�....::.,.... . .. .•�IitO RE.NtIMR .
Building Department
Occ Group, U- Type constr. v UAlW1
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
I
Valuation $ >
l
........ ...........nv:.....:. ..:..._........... ............:.:. .... l....:....
.................. :r:.•:: .......}..}.v:w::._.�:v.:v.:x•:::A::v::.::::.v;...n.•..nn........... ::}::ew:n:::�::.:�.:�::.:.. ..:::;n•.
.......r......... :....... ..v:.::.:::::::::::::.�:::::::::::. v::::::.... ... .............v .... .. .............:...................n..T..........................
i:�Si:iiii::>.?ii:i`: ,v!::•:w::•:::: :. .. ..... vi ..........;.....v:...:::::::::.�::::::::v:i::i•:';.}•:v::;•i:i?ii}:4»y,(.•.}..;n:.....
Building Permit Fee
Plan Review Fee UFC Plan Review Fee
Plumbing & Base Fee Public Works Review.Fee
Mechanical & Base Fee Other`= ir,�
Wood/Gas/Pellet Stove Fee Othew
Violation Fee Pre ail at Submittal
T)TAL FEES i
� 53
7 PERMIT NO. BLD
MASON COUNTY
UILDING PERMIT PPLICATION_.
426 W.CedariP.O.Box 186,Shelton,NSA 08684
Shelton 360 27-9670 Belfair 360 276r"67 Elnu tl $ Seattle 206 968 .
APPLIC,ANT INFOR
, MATION CONTRACTOR INFORMATION
Owner ' ii med Contractor Name L �i z3- t •mil% 4 7i'u.�
Mailing Address Mailing Address e
City = i State Zip;Code. City ,;`1-f �, ✓ State Zip Code rS /
Phone( )31aG3 O#her 'h.(; ) Ph.( 5�� - Other Ph.
t Lien/Title Holder. ) i i"�;� Contractor R.eg. # {.�/ Z�C-5?v 2
Address Expiration D'25 l Z l oe go
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septjc_____,,_Connect to Sewer
System Name of Sewer System Well Water System Name of
i Water System
P CEL INFORMATI9N•12 digit Ta Parcel No. • ` Fire Disttict_.3"""'.
gal Description
Site Address(Please include treet name, street number and ci y) f t
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No) Ald
Is your property within 200' of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Add it Repa• Other Use,o iluil�i
Describe Work
No. of Bedrooms No. of athroo s SQUA E FOOTAGE-1st loon 2nd Floor
3rd Floor Loft Basement •Deck_ _Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make . Model 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.
NOTICE: THIS PERMIT BECOMES NULL d.VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by,- i A1ttli below;-
fi
OWNER APFIDAVIT-1 certify that I am exempt from the requirements of thee ONTRACI C 'S AFFIDAWTa certify thM lam.currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and1hat I am-aware of the ordinance r
requirements for which this permit is issued and that all work will be done in requiremen rggulating the work for which this permit is issued and all work
conformance therewith, No changes shall be made without first obtaining shall be a Ih nformance therewith. No ch es shall be made without
approval. first o ai al.
X s
Date x' y • X Date
FOR OFFICIAL US BEYOND T41S•< IN?` '
Accepted by Dat /_ mittal Amount Due + ' Receipt,N . . a,
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $ ;
:::::::.,.::::r..:::::}::.,.::}}}}::.}}::::.:::.:.4;}:.}iY.......,n.:...v..:.:... .............::::::.4..................-....:..-:.:. /.................. ....r, + ....:. ..:C.rv:
..... .. ..: ::.. ......................................... ...............................................:::::v.�....::::.... .�..:.:..�:::::::v:::::::::•......:........-:::::::::vv.�r:::nw:.w::::::::.w::v:u::::::::.w:::::::::.�..:::X':::4}:4:G'+
Building Permit Fee Site Inspection
Plan Review Fee an evtew J
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Othe
Ta
i
Wood/Gas/Pellet Stove Fee Other
Violation Fee Pre-Paid at Submittal ( )
QTAL FEES 41P fo_
CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas piping date by
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by i
PLUMBINGAttic OTHER
Groundwork
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date 0-.jZ)I by L,/ date by