HomeMy WebLinkAboutBLD2002-00902 Replace Deck - BLD Permit / Conditions - 7/8/2002 FORM MUST BE COMPLETED IN INK PERMIT NO.: BLD
PLEASE PRESS HARD MASON COUNTY
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 Seattle 206 464-6968
APPLICANT I FOR ATI N (� �—� CONTRACTOR INFORMATION V
Owner �rioc�7 (" l �_ Contractor Name "" ''V\, 6` 0
Mailing Address 6105 6.0wo'lMailing Address
City State A4r1 Zi ode S'Sg39 City bLY)K014 StatevAIAr' Zip Code !3135-D
Phone(l q!-{/, Z�Tl�OT ther Ph.( Ph. they Ph.(_�
Lien/Title Holder Co
ntrac or Reg. # S Cct C- 9 SD L—A
Address Expiration Q&
SEPTICIWATER 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. / 2 / DD 0(p Fire District
Legal Description
Site Address(Please include st,Itreet name, street number and
Directions to site121=
Will timber be cut and sold in parcel preparation? (Yes/No)�(Z Ls��� �AlL�^-
Is your property within 200' of the following: Body of Water (Name) � Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENC
[No.
F JOB New Add Alt Repair Other e f B ing
UAD
e Work l OTC
edrooms o. of Bathrooms QUARE FOOTAGE-1st Floor d Floor
or Loft Basement Deck Other sq. ft.
Attached Detached Carport Attached Detached
I
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)
s Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS 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 described 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-I certify that I am currently registered as a
Contractor Registrati 27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requireme which this permit is iss d and that all work will be done in requirements regulating the work for which this permit is issued and all work
co n here ith No changes shall a made without first obtaining shall be done in conformance therewith. No changes shall be made without
j appr a. first obtaining approval.
pp,, X
X Date Date
FOR i
ICIAL USE BEYOND THI.UR(JIN�IS&52'3
Accepted b Da Submittal Amount Du� t��-- C_ ceipt No.
.
DEPARTI1llENTAI: EEVIW APPROVED R�NIEp C7NDITI+J CC1p
Building Department
l Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
i
I
Fire Marshal
I Valuation $
I
E
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee Planning Review Fee
Mechanical&Base Fee Other
11
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal ( )
El TOTAL FEES
THIS PARCEL
INCLUDES
PLANS, BLUEPRINTS
OR. OVERSIZE
IMAGES
LARGE FORMAT
IMAGES HAVE BEEN STORED IN
FILE CABINETS) UNDER
PARCEL NUMBER
PARCEL # U qA s
CASE n
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