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Ee = 0 ® G0 ] £ § g (D » = a@ \ � \ ( m \ _cn (D _ / = 7 g. co 23 ƒ * 0 CD/ k\ cr M. 7E =\ o = $ E — 3= ] CD C S \ ± 5' E = CD \ / f J a = \ / \M / / E CD CONCRETE MECHANICAL MOBILE HOME Footings-Setback date by Ribbom 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 ., ev-= Walls FIRE DEPT. date _: by / .�� date by date by PLUMBING Attic OTHER Groundwork date b date by D.W.V. WALLBOARD NAILING date by date /- D I by ( - Water Line FINAL INSPECTION date by date 2S _� by C date by z, l.. t �z �� L Q L.�✓� L r c- i ,4F/ c i f�ci r riiv.Ooi'uCS SFC_r� G�c /ter-= /F '� i� ro FORM MUST BE COMPLETED IN MK PLEASE PRESS HARD PERMIT NO.: OLD MASON COUNTY BUILDING PERMIT APPLICATION 112e W.CedariP.O.Box IN,ShdMn,WA wlt4 Shelton 0 27-as70 BaUair sa S-VI MW411111101141211111 Seatllo :AN:T INFORMATION CONTRACTOR IN ORMATION E ACC Contractor Name O ss t/ Main Addresti N2' State ! Zip Code City State Zip Code 17 12G5 Other Ph.C � Pn.(iCcd )7 Other Ph.( JLien/Title Holder Contractor Reg.ax Address Expiration_QL/ / F.PTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic, Connect to Sewer System Na a of Sewer System Well Water System�_Name of Water System PARCEL INFORMATION-12 d' it T Parcel No. Z Z O /S� / O Fire District Legal Description ! d7w Site Address(Please include street name,street number and ) .S DirgWans to site O Will timber be cut and sold in parcel preparation?(Yes/No) Is your property within 200'of the following:Body of Water(Name) Saltwater Lake River/Cfeek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs PERMANENT RWOMMJN SEASONAL f1ES11 ENCE 0 TYPE OF JOB New Add_ Alt Repair Other Use of Building Describe WorkE No.of Bedrooms No.of Bathrooms 1 SQUARE FOOTq�E�-1St FloorQQ`72nd 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 S Replacement Unit?(Yes/No) Installer Name Certification No. NOTICE:TWIMMIT BECOMES NULL A VOO IF WORK OR CONSTRUCTION AVTHOFUZgo IS NOT COMMENCED wrrmm 7ae DAYS OR IF CONSTRUCTION WOW la SUSPENDED OR ABANDONED FOR A PERIOD OF 1ae DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. j PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.The omirw or agent on owner's beMlt represeMa that the information provided is accurate and watds employees of Mason Cowry somas to the above desaibed property one structures for review and inspection of this Proud Ackeowledgmeffl of such is by sgiialme below OWNER AFFIDAVRa os*that I sm saemiA hom the requiremarts of 0r CONTRACTOR'S APPDAVRd as"awl I am cwew y rgl Wed ss a Carmww ReOvaden Law ROW 1e.27 sod am awsNe of lie srdinarm contnlcw in 0r SW of Wa4:nyton and dw 1 am owe slow ordirmave Iequremmis for which this p wird a issued arld dal a0 work will be done in requi cum is itplabq eie work far which Oils wnrormaNiw Thalstrsh Had. Hlal be made-OW-4 IiM Permit a kMNed and all work obta" be done In eaJornwlcs Ilmewilh. No shall be made without firn" �v E x- FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. Building Department t, " i Occ Grou Type Constr. Planning Department Environmental Health Department Public Works Department Fire Marshal t C valuations f Bull ft Permit Fee Site Insptiction Plan Review Fee EH Review Fw Pkar"V&Bose Fee Plet m— Review Few* lAedlanical S Base Fae ply WcodfGaWeNet Stove Fee State Fae i Violation Fee Pre-Pap at Submittal ( ) TOTAL FEES a U4/UJ/ZUU1 10:50 FAX 300 427 7796 MASON CO PERMIT CTR ©_ 10002 s� MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT p� t D Pl.nning C ' /�Q Mom County BI�.1 411 N.SM RO.sox 279 8hemn.WA oosm 'ry' (360)427-9670 Bow(350)275-4467 Elmo(360)492.5269 e� RNAiIES'i' FOR BMDING iTION NAILING ADDRESS: 17 1 :7 -r�ty 41//:r W .6/L-7 d. &W-& WA PARCEL NUMBER: / Z Z Z O -<Z OOD D/ LRGAL DESCRIPTIONt 641CU l44,12 1/1C.L%L- 6 l2 iSloA) 3 =,,fir 1 SITE ADDRESS t 330 if /-4&=966a 444:16& V,* 79'52- y REQUEST DUE TOt MEDICALLY NECESSARY FIRE DAMAGE EXPLANATION OF $ARDSHIP: _;?C-'`"/7a/Uc'E 6141 tar /-3 C QzuP�p UAVri 4&z5 ,fro (�ti►tn%�Lup v �K/D MUST IXCLtMR SUPPORTING DOCENTS, THIS MAY BE A LET= FROM A DOCTOR, IN CS CLAIM REPORT, OR REPORT OF FIRE MWAGB FROM APPROPRIAT8 PIRS $gyp ilENTATIVE I(WE) UNDERSTAND THE INTENTION OF THIS FORK IS TO DETERMIN8 AND DOCUMENT JUSTIFICATION FOR =PEDITION OF A BUILDING PZRXXT TO ALTER OR RECONSTRUCT A RE ZDENC4 QX I= ABOVE XwmD PROPERTY. SIGNATURE OWNER/AGZxT /V OFFICIAL USE O]aLY REQUEST DENIED FOR FOLLOWING REASONS) RBOUEST APPROVED. DATE: SIGNATURE if-WA UL DIRE OF ITY DEVELOPMENT ASON COUNTY PROJECT SITE INFORMATION J^I jam, jJ j Case No. PARCEL NUMBERL V,0101 Date SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan F—LOtDimensions Fences Existing Structures Driveways Structure Setbacks Shorelines Water Lines Topography N Well Location (including adjacent) Drainage Plan Names of Streets Easements Names of Fronting Streets Septic System DRAW SITE PLAN BELOW Include adjacent pro erties if on shoreline or within 100 feet of adjacent pro pert line. adjacent property line- I I ('adjacent property line 1 t I I 1 I jtl I t I 1 1 � I y I I I I adjacent property lined 1 I Idiacent ro ert line SAMPLE SITE PLAN - '""`""� �� � qA - adja�nt property line4 _ t i � I p 2La, 30, r SCRue _ E-adjacent property line SEA Z%JAL- C fi mom a- _ -'PTSL_�I J. rk F 'ie I Hcru� I. 1 PRO Pmv-aSap+-: VAGwT I I I` CA MAO,& I . I 30 1 i I VaoPoscn j T A&RLdLLLT�RAL 50 90 I I I I I I L—e-LL I I I I I � I adjacent property lined ' \; (-adjacent propert'line TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the degree of slopes. See sample topography profile.) SAMPLE TOPOGRAPHY PROFILE dtstor.ca to ruLt'L�NL d�ai'�►,cc to dis+anc� ie t / Signature Date' MASON COUNTY P.U.D. No. 3 OUTAGE AND SYSTEM ACTIVITY REPORT 3 NAME r W.O. # 0�� — % �Sl7 LOCATION 33 Z ����` < ,�"D .� OUTAGE DATE FS/SN -— i c' TIME CALLED_ i cj a 5� PHONE# MTR#_ RESTORED DATE_ NO. of CUSTOMERS (EST)_ / RESTORED TIME C) EQUIPMENT OVERHEAD UNDERGROUND SECTIONALIZING INSTALLED PRIM. [ ] SEC. [ ] PRI. ( ] SEC. [ ] FUSE OPERATION DIG-IN [ ] O.H. TRANS. ( J CO# LINES DOWN [ ] CABLE FAULT [ J O.H. FUSE ( J MFG. POLES DOWN [ ] SPLICE [ ] URD TRANS. ( j SER. # OVERLOAD [ J TERM [ ] URD FUSE KVA CAR/POLE [ ] ELBOW [ j RECLOSER f ] AMPSTREE ON LINES [ ] LBC [ J EXIST. IMPEDANCE BIRD/ANIMAL [ ] BETWEEN SN NEW POLARITY CUST. PROBLEM ( ] SN BILLING REQ'D [ J CUST PROBLEM EQUIPMENT FAILURE OTHER [ ] BILLING REQ'D ( J REMOVED [ J OTHER CO. # CREW REG O.T. MFG. HRS HRS PARTY TO BE BILLED: PHONE: SER# �� J KVA NAME: AMPS IMPEDANCE ADDRESS: POLARITY Auto Accident Tree on Line TRANSFORMER [ ] TOTAL Dig-In Customer Problem RECLOSER [ ] REGULATOR [ j FOREMAN'S COMMENTS: Q e c. L a i \ d v f i y 'tt�c N T G( 1 PHASE f j 3 PHASE f l POLE MOUNT [ ] PAD MOUNT [ ] VOLTAGE: WORK DONE TO REP IR OR RESTO E SERVICE:7 PRI. / SEC. / CONDITION: .✓� ® C cam �G GOOD 7-0 BAD STOCK OR AN SUPERINTENDENT ENGINEERING [ ] SURPLUS [ ] / `J��--- 4/97 MASON CO PUD 3 Original-Engineering Yellow-Warehouse Pink-Transformer Shop nty.. Fire-`Protectionl'•District .tom- N•..:L" -J+: - .. .. .. _ _ ... f 7 _ - r _ `e'Re ort� - gin p Form r FD-53 Incident Nurnber: (jl -jo 1I Date: 3 31 Uait Number: EI S 1 Type of Alarm::1 1 Ce, Location of Alarm: �jU tAZ ,� Situation Found: p ; d r, _.J i�i:f.:,�.r_•��%\•: =-+"t�• 5:,.�T LY.i, �!L.i -_i11f'�.:. - .f.�:.4.•��' :Generallnformation _ Occupant Name: hone# (3(�,)Zj�- O Address: C t t r2 Property Type: c , W p� Ins ance Company: or'Motoi' . .ehicle cc Vehicle Year: Make: Model: Lic#: Vehicle Year: Make: Model: ILIcH7 . -.. _ .P ._.. .... _ :.f:4.�••i.`='r'f�1:f_�':r:+�':,'��l T•��:/i��.y�;'S�>'`:" Point of Origin: Cau : 1� s e Method of Extinguishment: Acres Burned: jAir Bottles d: Water Pumped: Hose Used and Size: size ft size ft Size ft Foam Used: if yes give amount used: i;�•%J:--a':C :7;: i;�::f° -:wrif: .:iJ.�,9- .rF%•i.=.^v: �j:" - •:s•:r• •�r - �. Complete fo>- all=S fore Fire+ -i _�C.dr' a3 f r s< _ Construction Type: IRoof Covering: Number of Stories: Smoke Detector Present: Yes Operating: Yes/No Extent of Fire Damage Extent of Smoke and Heat Damage: ;:?f3'r•_. -,s'iF^y^.�. t!�;KC.:t';:t.c.s;w�:..,r;e�a: p;:c`ir';�vr eta^a: 'r;•: - -.us,'.�t!: c�' - - <.:. 1. r`_ .:c :>i.,..�iE'2.2it[`:i r r :3;i3^?;.._i�F.,?�rC't�•y,;,:lr.F:.�:•zt y?,yc�'t:��T w c:.. •F� -..,:a-.u: o,i-.._.�,.r.'::y:•.,. _ r r f J •., i. �:s nK.M�0.�- ):.r..4.af•9;�bh..`.�.._7_f'.".,rr��::.?R:aT.�� *Y��Y�i;%iti i3O � �{.;. �`r•Personnel Responding to Alarm: 1 :316 PCkLA5 2 Q 3 4 — L` 5 r 6 7 8 9 10 11 12 Responding Apparatus(check appropriate boxes)in the blank spaces include the mutual aid units, E-51 E-52 n E-53 E-54- n E-55 E-56 n E-55 n E-59 E5-10 F-1 E-511 A-51 A-53 A-56 R-57 AIR-53 C500 C502 C505 n M 51 14 n M n Fire T e: Structure- - (� Car Fire Brush Fire E losion n Service CaIll n Other(explain ) Personnel completeing Report Driver: Officer in Charge: FD-53(6�sj. kC, r CCU P� Iwo N1��I�=ice > >• EM . Jpff Make a sketch shoving the position of unitv--t---pply-ith respect to the fire,Show the hose lines manned by this unit,approximate length and • �� N N N N O O O 0 • 0 0 0 o jc p c p w p 3 m ^ H 14m000 .11 c D c p co a M m m CL c !j! T 2 fll un W cn � p n c W 0 � — t0 p 0 m 2 0'CD a tv o N (n cn cn cn cn (D co O _O - S (D U' Z H C o r« o a D =O m 5' o 3< O d ao m ^ A oo v+ fD m N � N ►, "a M C j o ° n O 00 a 77 fl < y O OOQ ro 0 O Wol _. N w 0OQ H O Ln O LTI O U! ... to l0 ^ O z O O ON 0 0 0 3 m 3 cn cn cn 0 3 ' 4 �n CO S V OJ l0 •• N � a 0 o O O a 0 0 0 0 O d 00 00 cn cn Vf Cn cn N D O O m W . � D d _ d Cr F N C -Apr-04-01 12:42P R Musselman — Farmers Ins 360 297 5287 P_O2 FARMERS Northwest Pmm ti pepecialry Branch Claim,;Office fvtsap Annex M-8 PO Box 126 Port Gamble,WA 98304-0120 Phone 888-025-5053 Fax 3(>(1-297-5287 mycr musselman(4!farme tmiarance.com April 4,2001 Attn: Mason County Building Dept. RI?: Our Insured Un Ingrid Kager Policy Number : 90311-05-14 Date of Loss 3-31-01 Claim Number M8-106867 A tree fell on the property located in Lakeland Village on March 31,2001.Because of the damage to the hone.it is currently unfit to live in.We are incurring Loss of Use coverage due to this loss. Repairs need to be expedited as soon as possible since the house is not livable until repairs are complete. If you have any questions you can contact me at the above phone numbers. Roger Musselman Special Claims Representative -�..�.� fro; �: � r �� 6 • �. ;; ^� .,: , ` . ,-. �'- � � .. - - - � � �. � �f�. � � F � '� 1 �. '� l � �. � �� � •t' /�_ •�`� !'{ ` `T 4 }. 1 � �r `` +.7 J Y � �� �� i I� -�.; ,r, ' ;�� I l: v '' ' �, 1,. w �� i �,jj ♦ a V w 1 �. • I � S � !� �� p4 r. \1 �.� '�,'' rt _ % � � & � � � � • '�