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WALLBOARD NAILING date by date by Water Line FINAL INSPECTION date by date A�_ 242%cTJ by �"� date by � � O i is i [Ff kf� F V PERMIT NO.: BL SON COUNTY BUILDING PERMIT APPLICATION ` S �l f 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482.6269 Seattle 206 464-6968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner ontractor Name Mbiling Address - Mailing Address z City r+ State .Zip Code City State Zip Cod � Phone( ) e they Ph.( a ) ., Ph. they Ph.(316C «?, �•S Lien/Title Older Contra or Reg. ' Address Dw Expiration / / i SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic__g&,__Existing Septic Connect to Sewer System Name of Sewer System Well Water System Name of j Water System PARCEL INFORMATION-12 digit Tax Parcel No. Fire District Legal escription ite dress(Please include street name, street number and city j rections to site tJ a i Will timber be cut and sold in parcel preparation? (Yes/No) 0 1 e,. _ s your property within 200' of the following: Body of Water(Name) -f4A 0je.4 Saltwater Lake_ River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs I PERMANENT RESIDENCE❑ SEASONAL RESIDENCE i TYPE OF JOB New Add Alt Repair Other Use of Building Describe Wor No. of Bedroo UILIJIUM115 Z)UUAKt I-00TAGE-1st Floor or 3rd Floor Loft Basement Deck Other sq. ft. Garage Attached Detached Carport Attached Detached ,a MOBILE HOME INFORMATION-Make Model 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. i NOTtCE; THIS E.._ .l7 BECO/1ES NULL&V D 1F WORK OR� NSTRUCTION AUTHORIZEQ IS NOT COMMENCED WITHIN, 480 DAYS OR IF CONSTAULTION WURK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 D&YS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the information provided is accurate and grants employees of Mason County access to the above descriped property and structures for review and inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval. "j first obtaining approval. - Date#IL/7- 0 a X Date FOR OFFICIAL USE BEYOND THIS POINT ' Accepted by ` , Date-7,t f Submittal Amount Due 01 I Receipt No. 4 1 I :.:. ............... .......... RTM I Building Department 3 f ;: APPRQ�fIwD D�NII~I7' Occ Group Type Constr. Planning Department Environmental Health Department 10 Public Works Department i Fire Marshal Valuation $ ..... Building Permit Fee Site Inspection Plan Review Fee -Plan Review Fee 7— Public Works Review Fee Mechanical K Base Fee Other &" Wood/Gas/Pellet Stove Fee Othe -D Violation Fee �. Pre-Paid at Suba Wal ( ) ' v:?z# TOTAL FEES 1 :. 4ASON COUNTY PERMIT NO.: BLD� DO i BUILDING PERMIT APPLICATION '"" �,18 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 4825269 Seattle 206 464-6968 APPLICANT INFORMATION _ CONTRACTOR INFORMATION Owner- o„„� 6 - `A�� fi.c� 6,, ,; ,,,I Contractor Name I Mailing Address �. —" `" Mailing Address L City r Statei Zip od Cit ' SO? Ip Cod- Phone Other Ph.� .. Ph Other P -"ft— __&A Lien/Title of er _ Contr for Meg. # Address dv Expiration SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic —Existing Septic Connect to Sewer System Name of Sewer System Well Water System Name of Water System PARCEL INFORMATION-12 digit Tax Parcel No--)Z: ? C /Sb / awn AFire District f Legal Description Site Address(Please include street name, street number and city) Directions to site IN 44 Will timber be cut and sold in parcel preparation? (Yes/No) _ Is your property within 200' of the following: Body of Water(Name)444 Dry � Saltwater Lake_River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs PERMANENT RESIDENCE❑ SEASONAL RESIDENC TYPE OF JOB New Add Alt_ Repair Other Use of Building j Describe Wor ' No. of Bedrooms No. of throoms ' SQUA OO AGE-1st Floor, 2nd Floor 3rd Floor Loft Basement Deck Other sq. ft. j 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 $ Replacement Unit ?(Yes/No) Installer Name Certification No. NOTICE: THIS.PE13MIT BECOMES NULL 8 VOID IF WORK:OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF k CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 190 QAYS AT ANY TIME AFTER THE WORK1S COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that'the information provided is accurate and grants employees of Mason County access to the above described property and structures for review and inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval. first obtaining approval. Dat �� _ X Date FOR OFFICIAL USE BEYOND THIS POINT _ Accepted by Dateol Submittal Amount Du Receipt No _ U PARTWl N— -AAC RAPIPAQVED DENIED tJND1T k71V C)p . Building Department Occ Group Type Constr. Planning Department Environmental Health Department Public Works Department Fire Marshal Valuation $ ::::::::::::i::i':::�: .... ..':::i::::::i::::::i::::i::::iii::::::i::::ii::::::iiii:�:t::::ii:'::�:::::i::t.::: ::::::iii .h......:.. ::..................... ........ ....... ....... ......... ......................:........ 41 ::%::::::'.:::;''::::::::::'::::' %:::: ':::::::'::::'.,:: ::::::::::::ii:::::::J Building Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee Public Works Review Fee Mechanical & Base Fee Other Wood/Gas/Pellet Stove Fee Other Violation Fee Pre-Paid at Submittal ( ) .. ...... .4 .i:: .:fi,'/':.++.+:�:'4:::�`�:.' ..•:$:'iv'Sri•.,%%t:.'::}:•j;$:•,:%•}�..::.wn�. •?1::...... :}+ :.:::< :k�k•}... .::. }:::.>.:::•;:: } TOTAL FEES .. ...,�.,}•:.kr.;}�°d ;f :... :.:: ses•.}q} •.. ...•* �•• 'i�tiiy`:{590}>}. <•y'.+r;::' �:'::�:'t:: '#:'t�::'.>:}i::r•}{••a.c%.•.idiawcucoc�.art•'ki!s•:•:.<:''v.S3N:}• ',�'`+}.ten�.�:'a1.lvx•. :,dv;•�••:'x•}:.>:•: �•�.,•: FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION �-�— Case No. Name /- 1��n -T u 1 PARCEL NUMBERc1(9 3 30 -5D--OCQg6 Date SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan Lot Dimensions Fences Existing Structures Driveways Structure Setbacks Shorelines Water Lines Topography Well Location (including adjacent) Drainage Plan Names of Streets Easements Names of Fronting S"--f- Seotic System H0WZ" L A e.r DRAW SITE PLAN E�.o �- "' _ _ .ent property line. adjacent property I` i--�- E`er 9-' Ijacent property line Uj O.COoosEOZD nJE D.e.ccEa.u:� 3a- ZJ 00) M Mon ¢2 ��uw S 1 A Z <Q O I ! O 4tD 9139,JD—Al) F/N,,L DU_W, WO 0 a} Wi h I til�p v z �°om} < Z<$ Via} z )}a \ kn �� \ n yea o N (9 _J CL d bEaJ rZoO GAL ) Q, Itfid J J '6 IbN¢ ,... O .� `� �. u�aW V pni z z a "6W rvca GAL.Pu nuJr I NNNO Q Z i'J C� 0wmv 3 \ z -Fufi RL rm.�s 3 m a C7 W turooF9 & 1�.�Glt' H ith Sentii CO� A; PiZ ED U 2 Z TH7s H2EH /a ' BE l-0 F.LLFI A:ID sE.O AS Initial& LL `r 7c:7n.Vi. V accEss,a uc/c Ides / 2at4 ..` ill Q pwev \ adjacent property I<g ___ Ijacent property line 0 c y' � C. SAMPLE SITE PLFD8 E��. � - -- -- ------ sIe.Z74- �� C. adjar�nt property to o w SLErVeD PualiL,ue ,�T,,/G ���E55 '44t 0 UT,L,TYE y/n7, �!# jacent property line *FA %)AL.. VACANT �s�o .+VIf <>zo o E M+ J' O.—9 BE.Cw.-vJ At ' V LtiY.47/- /DO, rAlluYry-LiLvL.CSR.r,)'N +YegG I \ I I I /D0 •I I La.+GLL. M's adjacent property line- ; l ' E-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 3o Pa 6 als+a.,u. to -L46r� t7llSTiel0:1 Zp/ Aft dc�taree to p � Slops, f-n¢ 041010 1 P LAlcz" f Signature Date FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION ,y 2 Z 31CyS"(j — I CGZ(ygase No. Name �-4' 7- -TArVV 0AJ PARCEL NUMBER Date SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan Lot Dimensions Fences Existing Structures Driveways Structure Setbacks Shorelines Water Lines Topography Well Location (including adjacent) Drainage Plan Names of Streets Easements Names of Fronting Streets Septic System DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line. adjacent pro ert lin adjacent property lin Q o f,.�X►St�N i O I\ vjCLL N� RV-60) ppivav Wfize_ EXISTING p. I Jl sns StAe-K , r n �I M I �V s0� e•CK 10'yC 5' N adjacent property line4 L werw v ' E-adjacent property line 7'ANq ys9 -- 6lArrsn/rN RoAD SAMPLE SITE PLAN adja�nt property lined v 3iO� 30. rRvE Fadjacent property line I a 3c-+I CREEK \ fi MOM tr i GnsEW \ rk I j40MOca,sQ 0 P0.o PostD � I VACA►X I C ARACa I P0.0p on 80, � I I I , /DO' I I I , I , /00' ., adjacent property line- i E-adjacent properfV 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.) 'Nib SAMPLE TOPOGRAPHY PROFILE �,ikrE Newer[ s/ dl s+a..cc to 'Zy I �• C �.�i ruct-LAYt �f 34'f' MK Slops. toe. dL � dis+anca. *e 19''1 � �w0. 6w,IcMtIID SI ature Date