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(D z 1) PERMIT NO.: BLD MASON COUNTY BUILDING PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton(36_Q427,79670 Belfair 360 2754467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFO MAT N CONTRACTOR INFORMATION Owner Contractor Name 4 V' yC-t Mailin A dress Mailing Address City State l`!4 Ip C ,? City State Zip Code Phone a J'75-C? 's`yOther ZGo Ph.(� Other Ph.( Lien/Title Holder Contractor Reg. # Address Expiration SEPTIC/WATER 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. / _/ Fire District Legal Description LOT 35 CADY5 NtL1,W O Site Address(Please include street name, street number and city) 107,q3 N iE All r-,-� Directions to site Will timber be cut and sold in parcel preparation? (Yes/No) Is your property within 200' of the following: Body of Water(Na e) 6F9- ' Saltwater ake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add Alt Repair Other Use of Building Describe Work E5rie .4110ILia No. of Bedrooms No. of Bathrooms J SQUARE FOOTAGE-1st Floor 2nd Floor 3rd Floor Loft Basement Deck72 ► Other sq. ft. Garage Attached Detached Carport Attached Detached 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) 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-1 certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance.therewith. No changes shall be made without approval. /� �I �f first obtaining approval. X / /V '4/ Date X Date FOR OFFICIAL USE BEYOND THIS POINT 5 Accepted by Date Submittal Amount Due Receipt No. .. .. . APPRLVEU E.DEPART-.MKNTA& I ........... ................ .......... ............................. Building Department Occ Group Type Constr. A IL Planning Department WWI i j Environmental Health Department Public Works Department I Fire Marshal Valuation $ ..: .:.::. .;.........:. . . . . ,. Fh>ES _ . Building Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee Public Works Review Fee Mechanical & Base Fee Other Wood/Gas/Pellet Stove Fee Other ` Violation Fee Pre-Paid at Submittal ( ) TOTAL FEES PERMIT NO.: BLD 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 INFO MATI N CONTRACTOR INFORMATION Owner Contractor Name 6 v Ajel2 Maili na Address Mailing Address City State__(&LAzip Code f'f�2& City State Zip Code Phone C7 4-75--0 Other Ph.(;tU6 ) yy!k� n31Q Ph.( Other Ph.C _) Lien/Title Holder Contractor Reg. # Address Expiration 'SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System Well Water y tern Name of Water System PARCEL INFORMATION-12 digit Tax Parcel No. / _/ Con V3 Fire District Legal Description LOT 35' C./4DYS 'Set 9t14eh Site Address(Please include street name, street number and city) .1071/3 N 1= Ala r'rN:!�A.rc- to-+-D Directions to site Will timber be cut and sold in parcel preparation? (Yes/No) Is your property within 200' of the following: Body of Water(Na e) _ca Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add-Alt Repair Other Use of Building Describe Work D 6 IL i t U i Q No. of Bedrooms No. of Bathrooms J SQUARE FOOTAGE-1st Floor 2nd Floor 3rd Floor Loft Basement Deck 11 1.cJjWIl!)ther sq. ft. Garage Attached Detached Carport Attached Detached 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) 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 Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval. Q first obtaining approval. X i� /�144� Date G X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. 4 ... .............................. €P,RRTME'—NT i..::R V� i+ I�Rc v # I?f»NI R NDkT[ N., +3CaE Building Department Occ Group Type Constr.e'U t0 ttj V_A, Planning Department Environmental Health Department Public Works Department 1 Fire Marshal Valuation $ ........._...................._..._.--.-..--.........:...-................................................................................................... ..........: .....:..:_..:..........:.:::.:.:::::::.::::..::....::.::::::....:.::.:::..:::: Building Permit Fee !3 .Sille Inspection Ong WTI=so a Plan Review Fee UFC;Plan Review Fee Plumbing & Base Fee Public Works Review Fee Mechanical & Base Fee Other �S7,T� Li Wood/Gas/Pellet Stove Fee Other 7 Violation Fee Pre-Paid at Submittal ( x ) TOTAL FEES FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION Case No. C?) Nam � �� PARCEL NUMBER 3 27-2 4-So — 0003 S Date SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan Lot Dimensions Fences E Existing Structures Driveways Structure Setbacks Shorelines Water Lines Topography Well Location (including adjacent) Drainage Plan Names of Streets Easements Names of Fronting Streets Septic System DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line. adjacent property line-> E-adjacent property line I I I N-rt 19�t I I I � all t► I I I ` I I � I ry I I I I I I I ww rr I I /V S O (' I adjacent property line- I E-adjacent property line SAMPLE SITE PLAN JJj gadEjAa.cSC wt/Aplr.o. pey line 3tO go• ,r�R 6_.S GSREPvTE_7 L___,� �II Faacent property line � V CREEK I Hot•tsfc 1 I j PrtoPmtn J F I 1'F— 6°• 130• —�I ' e I � 3� V0.aPmCD / T .sa.rtscu.trunA� 50• 1 � I I � I /DO" I � I I 1 � r--eC_L I I 1 I A /00" I I \ adjacent ro ert line4 ; '. Fadjacent pro pert'line TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the degree of slopes. See sample topography profile.) SAMPLE TOPOGRAPHY PROFILE �1'c Hdme rS otJtat�rc� to tL 2V e LAAJ17 Slopm tn¢ a,s+a..c-a. .e Signature Date