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FORM MUST BE=1PThelton
IN INK MASON COUNTY PERMIT NO.CA 01
PLEASM-C
oBUILDING PERMIT APPLICATION (tea
� 1 426 W. Cedar-P.O. Box 186, Shelton,WA 98584 C� (360)427-9670 - Belfair(360) 275-4467 • Elma(360)4 2-5 69
�? On the web www.co.mason.wa.us (�e$�
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner 1 Company Name
Mailing Address Mailing Address
City A tE to Zip Code 'd City State Zip Code
Phone 3&&215—4 aZ-Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic "Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. — Fire District
Legal Description
Site Address(Please include street name, street number and city) d E FE
Directions to site
Will timber be cut and sold in parcel preparation?Yes/ __ //--
Is property w' hin 200'of Saltwater cake River/Creek and
WetlandSeasonal Runoff Stream Slopes or Bluffs 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENQE ❑ SEASONAL ❑
Use of Building Describe Work
No. of Bedroom No. of Bathrooms Square Footage- 1st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
III
MANUFACTURED HOME INFORMATION -Make Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price$ 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
M APR RT SL Ip .INACTI OFT IS PERMITAPPUCATIONOF180 DAYS WILL INVAUDATETHEAPPUCATION.
Date: 6- 2.
X Owner/Owners Representative/Contra'ctor (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 Plannin 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 PERMIT APPLICATION
t , 1 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 ` 1 • �. :
helton (360) 427-9670 - Belfair(360) 275-4467 - Elma (360)482-5269
` On the web www.co.mason.wa.us C l
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner WASI) I QAD01414 1�0& D15T Ctity.,
*pany Name
Mailing Addresses 0 X Ind Address
1 tate Zip Code " State Zip Code
-
Phone -- 5 Z- Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address 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 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
Will timber be cut and sold in parcel pre aration?Yes A9.1
Is property w' hin 200'of Saltwater 2 Lake River/Creek Pond
Wetland 0 Seasonal Runoff Lj:; Stream Slopes or Bluff/o
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yos/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASO AL ❑
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor- 2nd Floor
3rd Floor Basement Deck Covered De(rk"l Other Sq. ft.
Garage Attached Detached Cafp oil---. -- Attached Detached
MANUFACTURED HOME INFORMATION - Make Model "' Gear
Length Width--Serial No. Nq. 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 ima stop work order or permit revocation.
Acknowledgement of such"is by signature below. I declare that I am the owner,;.ow hers 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 otherp",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 ano grar#ggrnployees of Mason County access to the above
described property and structure for review and inspection.This permit/application bm`es 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
MEA APRS�IJSP PN.INACTI OF T IS PERMITAPPLICATION OF 7 DAYS WILL INV ATE T.hJPPLICATION.
X 'Ur NOwr Date: r►
caner/Owners Representative/Contractor. (indicate which one)
F OFFICIAL USE BEYOND THIS POINT Accepted by: Date " -'
rBuilding
PARTMENTAL REVIEW APPROVED DENIED NOTES
De artment nnin De artment
vironmental 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 7, 49
MASON COUNTY PERMIT NO. 1lir 6 a-..
BUILDING PERMIT APPLICATION / ,a
426 W. Cedar•P.O. Box 186 Shelton, WA 98584 7 `J
4h;5it"on (360) 427-9670,r Belfair(360) 275-4467 • Elma (360ZT
w On the web www.co.mason.wa.us K
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner ,,,( Company Name
Mailing Address Mailing Address
City �► /� tat Zip Code a City State Zip Code
Phone '"YSVZ.Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.# f308 6 Drivers Lic.# DOB
SEPTIC /WATER'.SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well 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) 413 640 P
Directions to site
Will timber be cut and sold in parcel preparation?Yes/
Is property wi hin 200'of Saltwater � Lake River/Creek PondASQ
Wetland + Seasonal Runoff _Stream Slopes or Bluffs 15 I
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 RESIDEN E ❑ SEASO L'
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square Footage-1 st Floor 2nd Floor
3rd Floor Basement Deck Co ere j De z, Other Sq. ft.
fir Attached Detached
9
tiara e Attached Detached p
MANUFACTURED HOME INFORMATION - Make , ` Model "'dear
Length-Width Serial No. Nq: clfBeyroorns No. of Bathrooms
Type of Heat Purchase Price$ -Rpplacelnent Unit? Yes/No
Installer Name a 'Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may rests t in astop work order or permit revocation.
Acloowledgement of such is by signature below. I declare that I am )own&.,.awners I I reprggsentative,or the contractor. I further declare
that I am entitled to receive this permit and to do the work as propdA in the applicatiohY'l bdp that I have obtained the permission f€om all
the necessary parties. If permission is required from any easement holder or ny other,p"4h interest regarding this application or the work
proposed in the application, I have obtained permission from them to apply td r�t'h' permit a d conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is accurate an grant ployees of Mason County access to the above
described property and structure for review and inspection.This permit�dpplicati,.n 4 s null &void if work or authorized construction is
not commenced within 180 days or if construction work is suspendedYfor a p�i4 6f 180 days.PROOF OF CONTINUATION OF WORK IS BY
MEA APR REEro
SP Ip .IQNACTI �OFT IS PERMITAPPUCATION OF 18800 DAY L INVALIDATE TOE*PPUCATION.
X Date: c�C�
Owner/Owners Representative/Contractor (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 PlanningReview Fee
Mechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Pa' at Submi
Valuation $ FE
l MASON COUNTY PERMIT NO. CV4M
BUILDING PERMIT APPLICATION 426 W. Cedar• P.O. Box 186, Shelton, WA 985847 q
Kelton (360)427-9670 Belfair (360) 275-4467 • Elma (360w. '
i
On the web wwco.m ZX
ason.wa.us �
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner L� l Company Name
Mailing Address Mailing Address
City AP I tat Zip Code " City State Zip Code
Phone 2 " Z-Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address 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
i
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. -w Fire District
Legal Description
Site Address(Please include street name, street number and city) 413 5AD Lr -ORA-p9he-W IL
Directions to site Will timber be cut and sold in parcel preparation?Yes/
Is property wi hin 200'of Saltwater 140, Lake 61 River/Cree ip Pond
WetlandSeasonal RunoffL_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 PR MA Y RESIDEN E ❑ SEAS AL
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floot 2nd Floor
3rd FlobrT—Basement Deck'-�,,,rDe Other Sq. ft.
Garaged Attached Detached Nip Attached Detached
MANUFACTURED HOME INFORMATION Make Model
Length Width Serial No. t - e oo, ns No. of Bathrooms
Type of Heat Purchase Price$ r"l.,t� Icnt Unit? Yes/No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate in r ation y'rds t4 a st p work order or permit revocation.
Acknowledgement of such is by signature below. I declare that I wdn 1r">vv iers I sentative,or the contractor. I furtherdeclare
that I am entitled to receive this permit and to do the work as pr din the applic�tio)n I that l have obtained the permission ffom all
the necessary parties. If permission is required from any easemeolder qr other pyt interest regarding this application or the work
proposed in the application, I have obtained permission from them td. pgly r ptt a conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is=rate gra loyees of Mason County access to the above
described property and structure for review and inspection.This pe pplicati.n s null &void if work or authorized construction is
not cofnmenced within 180 days or if construction work is suspend or a �q�'M 1 0 days.PROOF OF CONTINUATION OF WORK IS BY
MEA APR R SP INACTI OFT IS PERe4O LIGATION OF 180 DAYS WILL INVALIDATE TF,�J4PPLICATION.
X � Date: 6— 2 5 "-0
Owner/Owners Representative!Contractor (indicate which one)
FOR OFFICIAL USE,BEYONp THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building De ertment
Planning Department Qoo -a0/�J ✓�O� ia,
Environmental Health Department
Fire Marshal CS 4-! ss �c
FEES'
Building Permit Fee /I Site inspection
Plan Review Fee a•3 I EH Review Fee
Plumbing & Base Fee �' Planning Review Fee
Mechanical &Base fee Other - L fr 3�'•
Wood/Gas/ Pellet Stove Fee State fee
Violation FeeQ4o3-coa0my 7 re-Paid at Submittal
Valuation $ Zol X ��},( = `>t
34 TOTAL FEES �'