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Cedar •�P.O..Box 186, Shelton, WA 98584 Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma (360) 482-5269 r On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner N•(�� F R0 *-� F f riz. ompany Name Mailin Addres -0•,Box Z Mailing Address City �+/K�State f d dip Code Ss City State Zip Code Phone,36 17;,5-fYfy 5 Other Ph.C3L0 Phone Other Ph. Lien/Title Holder Contractor Reg.# Exp. E mail address P1,45o143 C_ C#4k7*-,#- .Kp ?' E Mail Address 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. 2 O© Fire District - Legal Description MAS 0 12 25' .Aal©W IS Site Address (Please include street name, street number and city)y;.2LTo & ('gj�;eeV'fcce-i ®w /cad Directions to site 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. e TYPE OF JOB - New Add )C Alt Repair Other P IMARY RESIDENCE F1 SEASONAL ❑ Use of Building !lte,D�,oT. Describe Work �z �+ a r.�►no.�. �c,e No.of Bedrooms No.of Bathrooms Square Footage - 1st loor 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 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 permis- sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica- tion or the w r ro n the application,I have obtained permission from them to apply for this permit and conduct the work proposed. X Date: /tJ Z-7 0 3 O ner wners Representati /Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department -ra S- fG a Planning Department En ' _ �- Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Ins ection tuuj Plan Review Fee EH Review Fee 426 W- CEDAR Sz 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 • PERMIT NO.i MASON COUNTY ' BUILDING PERMIT 'APPLICATION 426 W. Cedar• P.O. Box 186, Shelton, WA 98584 .Shelton 427-9670 • Belfair (360) 275-4467• Elma (360) 482-5269 On the web www,co.mason.wa.us PAPLICANTINFORMATION -CONTRACTOR INFORMATION ner •e-. f r .- rn, `Dompany Name Mailin Addres Mailing Address City "R -1/2'e. State j _Zip Code City State Zip Code Phone = °` Other PhA0,14 P- f V Phone Other Ph. Lien/Title Holder Contractor Reg,# Exp. E mail address 1*/,4 "j 3 C"flr,e In,A. - At- E Mail Address 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 N Fire District Legal Description AIA So Lz 1.1— 5cov fy rot Site Address (Please include street name, street number and city) Directions to site 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 1 15 Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action TYPE OF JOB_ - New Adder_Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑ Use of Building 7"IA - t 1;� Describe Work ' ,-' *' zat We X A.- ., r,+?-,~ � 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. 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 permis- sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica- tion or thew rl�proposed in the application,I have obtained permission from them to apply for this permit and conduct the work proposed. X --,.. Date: ld� '� 3 Owner wners Repre entaq /Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Departure t Planning Departm nt Environmental Health Depa meritAu Tim rAr Public Works Department Fire Marshal FEES Buildina Permit Fee Site Inspection Plan Review-Fee EH Review Fee Plumbing& Base Fee Planning Review Fee • CEDAq Mechanical&Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES