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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 APPLIC T NF R TION CONTRACTOR INFORMATION Owner f -9 tijOJ _ Company Name Mailing Address .tJ6"144 L&P �*f Mailing Address City fi01A'V,4 State W✓* Zip Code City St Zip Code Phone 3/G r J?7`b�2 Other Ph. Z t 7 Phone Other Ph. r Contractor Reg. Exp. C mn4l address E Mail Address # 9gl3-_ 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 Pa[pel No. Fire District Legal Description - 11 _ Site Address (Please include street name, street number arA city) J( Dir ctions t ite GU Z i�� � Z �i� # w — �`� �/ g2 &.�t lcJ P&J Alt' /2NF iC 4Pvt (✓"&w-Ai it xzy z kZ c�'u "-4-- Will timber be cut and sold in parcel preparation?Yes No Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Strea Slopes or Bluff—T/o Is this permit submittal the result of a Stop Work oti e,Correction Notice or other enforcement action?Ye o TYPE OF JOB - New Add Alt Repair Oth r PRIMARY REj§jD C 'EASONAL ❑ Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage- 1 st loot 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 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 18 days or if constructi n work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANSOFAPROGR I PECTION.INAC VITYOfTHISPERMITAPPLICATIONOF180 AYSWI INVALIDATE THE APPLICATION. X Date: 4� caner wners Representative/Contractor (indicate which one) ' FOR OFFICIAL USE BEYOND THIS POINT Accepted by. Date - -L 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 Planninq 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 N(Sr—� L-- L4— yJ Cl 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 vNAmco.mason.wa.us APPLIC T tNFQR TION CONTRACTOR INFORMATION Owner Company Name Mailing Address I luF ,$d Mailing Address city- --AIA yV# StateWA-Zip Code FF City_ 6t Zip Code Phone 3/G"J'77-6712 Other Ph. 2CO/-&7 Phone Other Ph. r Contractor Reg. Exp. Fraiecs E Mail Address Ociuers,Lic..#, .,ggg,,. 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 TION - 12 Digit PaTael No. - Fire District Legal Description -zww' Site Address (Please include street name, street number arA city) �( Dir ctions t ite 'f Z ,w � AIA O'er -AP_ .r fhb ov e?ZrF GUr� G, Lr ,1 . ," ,�1W QN E� Will timber be cut and sold in parcel preparation?Yes No Is property within 200'of Saltwater Lake River/Creek Pond Slopes or Bluffs 15/o Wetland Seasonal Runoff Strea p Is this permit submittal the result of a Stop Work oti e,Correction Notice or other enforcement action?YekNo TYPE OF JOB - New Add Alt Repairl N Oth r PRIMARY R ID C ASONAL ❑ Use of Building Describe Work No. of Bedroom 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 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, represent i.4at the informaticn provided is accurate and grants employees of Mason County access to the above described property and structure forxevipw and inspection. This permit/application becomes null & void if work or authorized construction is not commenced within 18 days or if tructi n work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS OFAPROG I SPECTIO4,NACYIVITY OF THIS PERMIT APPLICATION OF 180 YS WI INVALIDATE THE APPLICATION. X Date: ' G� caner wners Representative/ tractor (indicate which one) FOR OFFICIAL USE BEYOND TH POINT Accepted b 1011 LA I Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Fire Marshal y: 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