HomeMy WebLinkAboutCOM2005-00080 Final Alteration to Sign - COM Permit / Conditions - 8/1/2005 n
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FORM MUST BE COMPLETED IN INK MASON COUNTY
PLEASE PRESS HARD 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 www.co.mason.wa.us
i P P L I CA NTjN FORMATION CONTRACTOR INFORMATION
"e Company Name
Mailing Address .d' o Mailing Address
City tate Y1A Zip Code City State Zip Code
Phone 0- '" 7 Other Ph360-,2'1.9- V7$9' Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address W;e S 1 k 1A W 01k e('a c- Co t'N E Mail Address
Drivers Lic.# SS DOB �� /D _,S Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic existing Septic
Connect to Water System Name of Water System
Well Water System Name of Water ystem
PARCEL INFORMATION- 12 Digit Parcel No. Fire District
Legal Description
Site Address(Pie incl de street name, e nu er and
Directions to site
Will timber be cut and sold in p cel reparation?Yes/No 41E;r
Is property within 200'of Saltwat Lake CreekPond
WetlandSeasonal Ru Stream oes or Bluffs 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB- New Add Alt Repair Oth� PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building f v- Describe Work
No.of Bedrooms No.o Bathrooms Square Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? Yes/No
Installer Name Certification No.
OVVNER/BULDER Advrowleciges submission of inaccurate information may result in a stop work order or permit revocation.Ackrxxviedgement 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 apply I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,rep*HIE t
provided is accurate and grants employees of Mason County access to the above described property and structure for review an
PROOF OF UATION OF ORK IS PY MEANS OF A PROGRESS INSPECTION.
x Date_ 'JUN 3 o 2005
Owner/ ers Her tali /Contractor indicate which one
FO CIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Departmen
Public Works 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
Violation Fee Pre-Paid at Submittal
Valuation$ TOTAL FEES
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
On the web www.co.mason.wa.us
APPLICANT FORMATION CONTRACTOR INFORMATION
9� �Q Company Name
Mailin _Address •d. C3dX MOO Mailing Address
City State WA Zip Code 2 9Sa 9 City State Zip Code
Phone-*;t60-,27S-677& Other Ph260-,a? 770' Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address f jes4 t IJ Q ueayet e-ab le-. Com E Mail Address
Drivers Lic.# 55 DOB /d-� ,V Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Water System Name of Water ystem y
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address (Ple incl de et name, gire nu er and ' )
Directions to site
Will timber be cut and sold in p cel reparation?Yes/No /
Is property within 200'of Saltwat Lake Rim(Creek Pond
Wetland Seasonal Ru Stream Slopes or Bluffs 1 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE E] SEASONAL ❑
Use of Building fart t;a IIt r Describe Work S /GA
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 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 applicap ILre
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represe I1laa
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROOF=TION OF ORK IS BY MEANS OF A PROGRESS INSPECTION. FJUN 3 ® 7nn;
X Date:
r wners RerntativContractor indicate which one)owne 8ELF4IR
FO CIAL USE BEYONDTHIS POINT Accepted by: Date
DEPARTMENTAL REVIEW OVED DENIED NOTES
Building Department •07
Planning Department
Environmental Health Departmen
Public Works Department
Fire Marshal
FEES
Buildina Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing &Base Fee Planning 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
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 www.co.mason.wa.us
APPLICANT FORMATION -N CONTRACTOR INFORMATION
'. fir_.._.._....... ,Q Company Name
Mailing Address_ PD• ryx /9(oo Mailing Address
City State A Zip Code 9'�''5-R F City State Zip Code
Phone-1&0-,2 7 'b'77 Other Ph 360:a`)S V 7944" Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address W@5 IJ QyjavaeahE Mail Address
Drivers Lic.# S.TM DOB �+�•/�-y3"^ Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Fxisting Septic
Connect to Water System Name of Water System
Well Water System-,-i—Name of Water ystem {t l e
PARCEL INFORMATION- 12 Digit Parcel No. Fire District
Legal Description
i Site Address (Please incl de atxeet name, e number an ' (Yl / 1
Directions to site —'
Will timber be cut and sold in P cel reparation?Yes/No
Is property within 200'of Saltwat Lake Creek Pond
Wetland Seasonal Ru Stream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?YesMo
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building Ad & l Describe Work S /GN
No.of Bedrooms No.o Bathrooms Square Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
I 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 applicationr�gd-p�
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents iitiaa D
provided is accurate and grants employees of Mason County access to the above described property and structure for review an i ion.
PROOF OF INUATION OF ORK IS BY MEANS OF A PROGRESS INSPECTION. �, i 3 0 7nn�
I X Date: � '�v"�"�S
Owner/ wners Re r entati Contractor indicate which one �BELFAIR
F04VFFrCIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
l Planning Department ft
Environmental Health Department
} Public Works Department
r
Fire Marshal
FEES
Building Permit Fee Site Ins ection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical &Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
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ENGR: CONFIDENTIAL PROPERTY OF SPECIALTY ELECTRONICS. NOT TO BE DISCLOSED TO OTHERS
REPRODUCED,OR USED FOR ANY PURPOSES EXCEPT AS AUTHORIZED IN WRITING BY AN AUTHO -SpM1�11Y[I CIY�pf CS LANDR SMG,SC
DATE: RIZED OFFICIAL OF SEI.MUST BE RETURNED TO SEI ON DEMAND,ON COMPLETION OF ORDER OR �NLYYIY GLLI1�INIINW
OTHER PURPOSE FOR WHICH LENT.
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