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Fail Date Date Done By Comments CD a 00 0 W Cn N r O 8 a 0 0 s m 0 APPROVED MASON CT �D PLANNING NNINGi; SITE NREQUIRED TO BE ON SITE O (T p y a ECT TO APPROVAL . � Y Date t7 e ® � J ND OD To- 1 W rn F L z —, _ t- o = Z n t! 2 c m -1 y� 2 r, •� ti m n1 z a � � y C/) C co �� O MUST BE OMPLETED IN I MASON COUNTY PERMIT NO. PLEASE PRESS HARD B 2� 00W ILDING W. Cedar.PoERMI ox $T6APPoLI APPLICATION FORMl Shelton (360)427-9670 • Belfair(360) 275-4467 - Elma (360) 482-5269 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner t,4jcAtrz,.L d Mms n-V51A Company Name 6moar, Mailing Address No Ne AMOLOSIMMailing Address City —State LAA Zip Code 993U City State Zip Code PhoneXM-333-902 Other Ph. Phone Other Ph. Lien/Title Holder `X'^*.- Contractor Reg. # Exp. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic C ect to Water System Name of Water System Well N Sewer System Name of Sewer Systena- PARCEL INFORRfA`T,IIO_N - 12 Digit Parcel Ni Fire District Legal Description Site Address(Please include street name, street number and city) 91 0 NIE 5taCN588 Directions to site Will timber be cut and sold in parcel preparation. Yes o Is property within 200'of Saltwater Lake River/Creek nd Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement actin Yes o TYPE OF JOB - New Add Alt Repair Other PRIMARY ES�IQENCE�❑ SE NAL ❑ Use of Building Er LAME Describe Worl�'���'r�� ��� "*''- d dl No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor I 3rd Floor Basement Deck Covered Deck Other UgjA . ft. gEr it I Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Ma f Mo 1 Year Length Widt erial No. No. of B ms No. of B ooms Type of Heat Purchas ce$ placement Unit? Yes/ 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 descri roperty and structure for review and inspection.This permit/application becomes null &void if work or authorized construction is not m Hoed within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 1 0 MS WILL INVALIDATE THE APPLICATION. Date: er Contractor (indicate which one) FOR I IAL USE B THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department _ Planning Department cool—) Environmental Health Department Fire Marshal FEES Building Permit Fee Site Ins ection 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 r 136')) MASON COUNTY PERMIT NO. � � IL DING 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 Owner N1► 'd MOC MLf �IJ4 Company Name 0 %3kAL0Efr_-- Mailing Address 3 Mailing Address City State WA Zip Code 92311 City State Zip Code Phone 3(o(b-:�33-9!}99 Other Ph. Phone Other Ph. Lien/Title Holder Mv"^f, 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 Cdmq.ect to Water System Name of Water System Well N Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. ZZ-330 50 &@MBdNa Fire District Legal Description HAVeA LAKE Site Address(Please include street name, street number and city) O NtW i V- NMI -ZLIM id �5 Directions to site Will timber be cut and sold in parcel preparation. Yes o Is property within 200'of Saltwater Lake River/Creek Rend Wetland Seasonal Runoff Stream Slopes or Bluffs �1 Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement actin Yes o TYPE OF JOB - Ne Add Alt Repair Other PRIMARY RESIDENCE ❑ S NAL ❑ Use of Building "Lam. Describe Work6 V(:r _M" SLngt.V- WbLL AfA i No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other L&ALLg ft. S %f Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Malmo! Mo I bear Length Widt Serial No. •�' No. of B MS—No. of B ooms Type of Heat Purchase e$ placement Unit? Yes/ 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 descri roperty and structure for review and inspection.This permit/application becomes null &void if work or authorized construction is not co m nced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 1 0 D YS WILL INVALIDATE THE APPLICATION. Date: er entativej Contractor (indicate which one) FOR CFJIOJAL USE HIS POINT Accepted by: L Date i DEPARTMENTAL REVIEW APPROVED DENIED NOTES I Building Department 3 1 / f Planning Department ^t1 Environmental Health Department ``rt.,, _ t. i Fire Marshal FEES Building Permit Fee 14 Site Inspection jPlan Review Fee _ EH Review Fee Plumbinci & Base Fee Planning Review Fee Mechanical & Base fee Other i Wood/Gas/ Pellet Stove Fee �— State Fee S Violation Fee - 13-0 Pre-Paid at Submittal Valuation $ TOTAL FEES S 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 Owner R1Kl1rSt�;, E# K'24C- 112u•,b Company Name Mailinq Address 3WI NF_ AnAi3LQi0C U4 Mailing Address City" State WA Zip Code 9231 I City State Zip Code Phone 3W 3`43-9427 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 C&Na,ect to Water System Name of Water System Well N Sewer System Name of Sewer Syste DC PARCEL INFORMATION - 12 Digit Parcel No. 3 Se 1*10.9 Fire District Legal Description }HQ21C_� LAKE Site Address(Please include street name, street number and city)VA(0 i3wicwtjij Q) -'ZMW LOA VT3 Directions to site Will timber be cut and sold in parcel preparation. es Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffer/a NV �_�'` Is this permit submittal the result of a Stop Work Notice,Correction ice or other enforcement actin Yes TYPE OF JOB - New Add Alt Repair Other Jr PRIMARY RESIDNCE SE NAL ❑ Use of Building s Describe Work(W42-ML7 9LV-` t"t LL No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered DecCR, ' Other ft ge 'i Garage Attached Detached] ` ' rport Attached Detached MANUFACTURED HOME INFORPATION -Mal As ___- M I Year Length Widt Serial No.. No. of B ms No. of B ooms Type of Heat PurQhase e$ 4� placement Unit? Yes/hie Installer Name Ceti ification No. OWNER/BUILDER Acknowledges submission of inac'curat`, m?tion may result,jif a stop work order or permit revocation. Acknowledgement of such is by signature below. I declare that ar the owner,owners.legal representative,or the contractor. I further declare that I am entitled to receive this permit,and to do the work a's.prop d in the,application. I declare that I have obtained the permission from all the necessary parties. If permission,il required from any eas6m elder o, 'any 4p1her party in interest regarding this application or the work proposed in the application, I haf obtained permission from them to'apply r this permit and conduct the worts proposed. The owner or ade,cril Umpertyand presents"that the infotmation provided is accurate and grants employees of Mason County access to the above cture for review d inspection. This perrx�ytlapplication tiecomes null &void if wor�Qt authorized construction is days or if constr k impendedf6ta period of 180 days.PROOPOF COWINUATION OF WORK IS BY SPECTION.INA, . OTHIS PERJTAPPLICATION OF 1 0 D YS WILL INVALIDATE THE APPLICATION. Date: nta6ye ontractor (indica 'CNCich otie) , FOR MINAL USE fIIS POINT Accepted by: c 1 Date J! 1LLLi DEPARTMENTAL REVIEW APPROVED - DEI tft NOTES Building Department Planning Department % �(_S'0 ;., �1 �-- ) . ; •; / Environmental Health Department `7�t ` `,�. �` r �l `- ul" i ' 1 Fire Marshal FEES Building Permit-Fee Site Inspection Plan Review F,a 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