HomeMy WebLinkAboutCOM2008-00119 Cancelled Retaining Wall - COM Permit / Conditions - 10/2/2008 C�� � ����
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NC
PLEASE PRESS HARD ILDING PERMIT APPLICATION
1.426 W. Cedar•P.O. Box 186, Shelton,WA 98584 (
Shelton (360)427-9670 • Belfair(360) 275-4467 - Elma (360) 482-5269Q
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION �� SON �.��✓�
Owner Lu- �t�IC i ` 12Company Name
mlap
Mail* d s 10 Mailin Address &O. x
City Statelkl id-Z*p C e City �- State - Zip Code
L Other Ph (� Phone d a Other Ph.
Phone - iC_._ Contractor Reg. Exp.
Lien/Title Holder E Mail Address ss`NG. '�e
E mail address Drivers Lic.# DOB
Drivers Lic.# 008
SEPTIC/WATER SYSTEM INFORM ATION - Connect to New Septic_ Existing Septic
Connect to Water System ..,,Name of Water System
Welk_,____ Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel N . 'Z OO Fire District CDC
Legal Description b FIE ��
Site Address(Please include street name, stet nu be and city) ,- "A.'
Directions Directions to site^nfi'>v&
Will11 timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of Saltwater �_Lake River/Creek Pond
Wetland _Seasonal Runoff Stream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF J B� New ArddT Alt Repair Other 10101"PrR PRIMARY RESIDENCE ❑ SEASONAL
L42::C AL
Use of Buildi _Describe Work �<
No. of Bedrooms_ No. of Bathrpom5 Square Footage- 1st Floor 2nd Floor
t.
3rd Floor_---Basement._.,.- -,--Deck Covered Deck Other Sq.Garage_- Attached .- Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
No. of Bedrooms No. of Bathrooms
Length_Width Serial No.
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
I
ers behalf, represents that the information provided is accurate and grants employees of Mason County access to the above
p operty and structure for review and inspection.This permit/application becomes null&void if work or authorized construction is
ced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY
FAP O RESS INSPECTI .INACTIVITY OF THI P��MITAPPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
Date:
Owner/O ner eprese tative/Contractor (indicate who one)
F IAL USE BEYONq THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
BuildingDepartment
Planning De artment
Environmental Health Department
Fire Marshal FEE
Buildin Permit Fee Site Inspection
EH Review Fee
Plan Review Fee
Plumbin & Base Fee Planning Review Fee
Mechanical& Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
Pre-Paid at Submittal
Violation Fee
TOTAL FEES
Valuation$
MASON COUNTY PERMIT NO(��,
BUILDING PERMIT APPLICATION 426 W. Cedar- P.O. Box 186, Shelton, WA98584 oo ' '
q
Shelton (360) 427-9670 • Belfair(360) 275-4467 - Elma (360) 482-5269
On the web www.co.mason.wa.us
ONTRACTOR INFORMATION
IF
APPLICANT INFORMATION 1.. ! !CUt ompany Name `' `� �.►S[�'� �•
Owner X
Mail' Addcss Mailin Address
City {-- State—Zip Code + city !VL State Zip Code
Phone � Other Ph. 7�(� Phone �(� 3 Qther Ph.
�/ ITSR P tN+L Contractor Reg. ExP
Lien/Title Holder - E Mail Address 7" — '
E mail address Drivers Lic.# DOB
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 Syste
PARCEL INFORMATION - 12 Digit Parcel N '�- O Fire District
N�1 �J M.� ��' •`rQS Li3T' " O G S#Ir?QT 7 v � �f
R^�
Legal Description le
Site Address(Please include street name, street num er and city) r • °�°��"'�'� '! L '
Directions to site r-O dCv 0 E �'I ' 'O'er Awc� tC�
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland - Seasonal Runoff Stream Slopes or Bluff/o
Is this permit submittal:the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JO - New Add Alt Repair Other PRIMARY� RESIDENCE SEASONAL ❑
Use of Buildi 1 � escribe Work�Lt�.. t2-ti:'sP I'�'Ns°' tP�L ICJ Pl3�C.Ka t.� LcT'1"<
No. of Bedrooms No. of Bathrooms_ Square Footage- 1 st Floor 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 s�gnature'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
party in interest regarding this application or the work
the necessary parties. if permission is required from any easement holder or any other
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
ed property and structure for review and inspection. This permit/application becomes null &void if work or authorized construction is
ed
desc n work is suspended for a period o ay
not c mmencpe within structure
days or if constructiof 180 days.PROOF OF CONTINUATION OF WORK IS BY
MEA FAP O ESS INSPECTI INACTIVITY OF THI$P��MITAPPLICATION OF 180 DAYS WILL INVALIDATETHEAPPLICATION.
€ X AAa iP\ Date:
Owner/O Hers eprese tative/Contractor (indicate whit one)
Y
Accepted b Date
FOWbF AL USE BEYOND THIS POINT NOTES
DEPARTMENTAL REVIEW APP D DENIED
Building Department
Planninq Department
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee PlanningReview Fee
Mechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee
State Fee 'r0
Violation Fee Pre-Paid at°Submittal
TOTAL FEES
Valuation $
r '
MASON COUNTY PERMIT N0( ( 42 1
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 c
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION jam,. CONTRACTOR WFORMATION
LPL , I<a tC_. 1`f �4 c Company Name "` - � �.j
Owner t` t its j(. t 0 1L Mailin Address " `--
Mailing Address, x,ate - City t ►t� State Zip Code
City § L { i � State\el_-Zip Code '
Phone „�. L7�1 q Other Ph.
, 1 Ft_k Exp.Phone�tQ K h Contractor Reg.
Lien/Title Holder
t "
E Mail Address C
E mail address Drivers Lic.# DOB
Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic 2 Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer Syste
PARCEL INFORMATION - 12 Digit Parcel N�Q( "x Fire District
' : L,OT G
Legal Description11
>
Site Address(Please include street name, street number and city) �' c +• T.t.� J_
C �1 +Jt c4) .
) 4 iGG i ✓ L l + n�4 1 ILL �t
Directions to site � 1`
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200' of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff�_Stream Slopes or Bluffs 515%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF J B i New Add Alt Repair Other PRIMARY RESIDENCE T SEASONAL ❑
�:. Use of Buildi escribe Work �lt- L r J 1 � �� e_c�'i
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor,
4 3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
No. of Bedrooms No. of Bathrooms
Length Width Serial No. Replacement Unit? Yes/ No
Type of Heat Purchase Price$ p
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 rE edf eermiss on d from from themtto alpply foder or r permit and conduct in thework propos this edllcThe ownertion or eo`r work
proposed in the application, I have o P provided is accurate and grants employees of Mason County access to the above
icn ro
Bents that the informat p authorized construction is
behalf, represents work or
agent on owners p
described property and structure for review and inspection.This permit/application becomes null &void i
not commenced within 180 days ECTIf construction.INACTIVITY OF THI suspended MITAPPLICATION OF 18eriod of 180 0 DAYS WILL INVALIDATEs.PROOF OF AT EAPPL CAT ON.BY
MEAN$OFAP O�RESSINS
Giyvl�,, IL.. _, Date:
X Owner/O ners'Represe tative/Contractor (indicate which one)
Date
Accepted by:
FOR OF AL USE BEYOND THIS POINT p NOTES
DEPARTMENTAL REVIEW APPROVED DENIED
Buildin Mepartment
Plannin artment I� v
Environmental Health Department
Fire Marshal
FEES
B u i I d i n Permit Fee Site Inspection
FReviewee EH Review Fee
ase Fee
Plannin Review Fee
Base fee Other
Pellet Stove FeeState Fee
Pre-Paid at Submittal
1
TOTAL FEES
Valuation $
MASON COUNTY PERMIT NO 4
BUILDING PERMIT APPLICATION
426 W. Cedar- P.O. Box 186, Shelton, WA 98584 l
Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATIONS �.
Company Name
Owner t <`,�.7 Mailing Address
Mailing Address A . p
City s c State Zip Code `
City State�_•Zip Code—',
` -"
...` . ., / � Phone ' : -. ?' . � •, w tt Other Ph.
Phone - - ; w Other Ph. t
i... Contractor Reg.# J Exp. i
Lien/Title Holder E Mail Address ` 4 `
E mail address Drivers Lic.# DOB
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 Parcel No. _# •7 Fire District
Legal Description - ;>
Site Address (Please include street name, street number and city)
-t
Directions to site
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200' of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluff 5%
k: Is this permit submittal the result of a§top Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building, X Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 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 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY
MEANS OFAPf QGRESS INSPECTION.INACTIVITY OF THIS PEVMITAPPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X _ Date:
Owner/O ners Represe.tative/Contractor (indicate which one)
FOR OFF1 IAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Buildinq Department
Planning Department
Environmental Health Department
Fire Marshal i#
FEES
BuildingPermit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee PlanningReview Fee
i Mechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
' Violation Fee Pre-Paid at Submittal
i
Valuation $ TOTAL FEES
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