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HomeMy WebLinkAboutBLD2007-00384 Final Dock - BLD Permit / Conditions - 8/20/2007 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.QUO --b PLEASE PRESS HARD BUILDING PERMIT APPLICATION 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 I FOR If CONTRACTOR 1 FORMAT ON Owner e- I Company Name Maili ddress +�` Mail Ad ss O City r late_ hJA Zip Code City State Zip Code Phone Other Ph. Phone © 2'7 S-S OtheLRh._ Lien/Title Holder Contractor Reg. K 1 S0. 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 INFOR ATION - igit Pa cel No. Fire District Legal Description I �� L- Site Address(Please includes eet name, street number c1nd city)Z3O -T-0. Sg Directions to site Q L \0 r o C PO YL -Z30 tl t O n Will timber be cut and sold in parcel preparat ?Yes Wo Is property within 200'of Saltwater Lake 4 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?Ye N TYPE OF JOB - New__Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage- 1 st Flo 2 d Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. —.57 2 Garage Attached - Detached Carport Attached Detached j 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 PRO RESS SPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: � � -'0 T5wnV7 Owners Representative/Contractor (indicate which one) FO 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-Paid at Submittal Valuation $ TOTAL FEES MASON COUNTY PERMIT NO. BUILDING PERMIT APPLICATION 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 OwnerCompany Name I Mailin Address +h Mail ;Ad ss City tate_�1QZip Code qS c7'.3 City State Zip Code Phone Other Ph. Phone Other h. Lien/Title Holder Contractor Reg. aKe C4 r 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 - igit Parcel No. J Fire District Legal Description 12 I 4 Site Address (Please include street name, street number and city) L-- Ce\Dr. Directions to site ` r 4 41 1 +' 1 Irr c�rL Z c Will fimber be cut and sold in parcel preparat ?Yes No 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?Ye TYPE OF JOB - New—)LAdd Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. 2 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 Fuhc�,e - 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 PROGRESS 1 SPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. X Date: Own Owners Representative/Contractor (indicate which one) FO OFFI IAL USE BEYOND THIS POINT Accepted by: Date E DEPARTMENTAL REVIEW APPROVED DENIED NOTES i i Building Department i i� Planning Department I Environmental Health Department Fire Marshal I FEES Building Permit Fee Site Inspection Plan Review Fee 0. 00 EH Review Fee Plumbing & Base Fee Planning Review Fee Mechanical & Base fee Other Wood/Gas/ Pellet Stove Fee State Fee Violation Fee C/ ,3 — �/' a7 Pre-Paid at Submittal i Valuation $ TOTAL FEES MASON COUNTY PERMIT NO. JC C BUILDING PERMIT APPLICATION 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,I FORMfION CONTRACTOR I FORMATION Owner K, Company Name ty ' I ►\` 1' Mailin Address t�` Mailing Ad�ss Q City tate Ih1a Zip Code City State Zip Code Phone Other Ph. Phone .> U Z"T Othe Lien/Title Holder Contractor Reg.# + �• 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 - 1? igit Parcel No. 3 Fire District Legal Description k'i L. Site Address (Please include stL,eex name, street number and city).Z.3 C> tl L1A V-k of. T .�, c k 1 Directions to site Will timber be cut and sold in parcel preparation?Yes 609 Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yeso TYPE OF JOB - New V Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage- 1st Flo 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. f Z 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 Purcha5 f rige. 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 1 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 PRO RESrIPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. 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