HomeMy WebLinkAboutCOM2008-00050 - COM Application - 4/11/2008 MASON-COUNTY PERMIT NO.
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 1 FOR ATION CONTRACTOR INFORMATION
Owners Ih Company Name
Mailin .Address Mailing Address
City c State Lug-ZfpCod E, _e `2 / City State Zip Code
Phone ther Ph.3raQ � ,4 Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic X
Conne t to Water System Name of Water System
Well Water System, Name of Water System
PARCEL INFORMATION-12 Digit Parcel No Fire Distri t
Legal Description
Site Address(Please inclyde street name,street number and city) 3 L fu PV=
Directions to site
Will timber be cut and sold in parcel preparation?Yes/ o f7ost FG"k qcMscf
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?Y
TYPE OF JOB- w Add Alt Repair Ot her�p� RIMARY SIDENCE❑ SEASONAL ❑
Use of Building Describe Work i 17�0 py,- af�t4�
No.of BedroomsNo.of Bathrooms Square ootage- 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 holler 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' accurate and giants employees of Mason County access to the above described property and structure for review and inspection.
PROOF CONTINUATIO OF WORK BY MEANS OF A PROGRESS INSPECTION.
X Date:
Owner/Owners Representative/Contractor indicate which one ^
FOR OFFICIAL USE BEYOND THIS POINT Accepted b : Date LV
j t
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department -�
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building 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 r
i Violation Fee /V / Fire-Paid at Submittal
i
Valuation$ Q-- / TOTAL FEES
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