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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 Connect to Water System Name of Water System Well X,__Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No 2 W Fire District Legal Description Site Address(Pleas in=,OeV ifname,street number and city) rt Directions to site Will timber be cut and sold in parcel preparation?Yes 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 Stoe Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB-N w Add Alt_ Repair_. Other ^ ,_ {MARY RESIDENCE SEASONAL Use of Building__ � Describe Work e d' lt�l 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 44 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/BU11.DER 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. PROOF OF CO A Ri OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X fi Date: � i� Owner/OwneterRepresentative t Contractor indicate which one' FOR OFFICIAL USE BEYOND THIS POINT Accepted by:.- Dat DEPARTMENTAL REVIEW AP P D 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 Planninq Review Fee Mechanical& Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee a Pre-Paid at Submittal Valuation$ TOTAL FEES C MASON COUNTY PERMIT N 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 IN F R AT ON CONTRACTOR 1 O A ON Owner eZe Company Name Mailin Add res SRI Mailing Address City A /-State Wd Zip Code City State Zip Code Phone-,42 215 -Other Ph. I Phone Other Ph. Lien/Title Holder I 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 Connect to Water System —Name of Water System Well ,X Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No Fire District Legal Description 2 Site Address(Please inelu st eet name,street number and city) ;o it Directions to site Will timber be cut and sold in parcel preparation?Yes N 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 StoE Work Notice,Correction Notice or other enforcement action?YesMo TYPE OF JOB-N w Add Ait_eK Repair_ a Other_,_ IMARYRESIDENCE EASONAL Use of Building-�� Describe WorkAlk 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. OVVNER/BLIDER 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. PROOF OF CO A OF WORT{IS BY MEANS OF A PROGRESS INSPECTION. X. : "`2r�' - l Y7 Date:_ 71 Owner/Owne a resentative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by:_ Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal S-2Z> 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 Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES i i MASON COUNTY PERMIT NCC�aff) � \ BUILDING PERMIT APPLICATION t 1 426 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 J APPLICANT IN F R ATfloN CONTRACTOR INFOIJMATJON Owner lY`C Company Name_D !1` ►ytt�e� Maiiin���re7 �K1 Mailing AddressCitytZipCodeCity State Zip Code PhoneOther Ph. 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 Connect to Water System —Name of Water System Well--.X---Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No Fire District Legal Description 2 Site Address(Please inclu stfname,street number and city) ? r­ Directions to site t�f et Will timber be cut and sold in parcel preparation?Yes 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 JOB-N w�___Add Alt u Repair___ Other IMARY RESIDENCEMEASSONAL rl Use of Building Describe Work e — , No. of Bedrooms /1 ' 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.Admo ledgement 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. PROOF OF CONTlWA7jON OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X. � 'f- - � d 77t- Date. Owner/Owne resentative t Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by:_ Date -- DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Departme 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 Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES