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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PRESS HARD BUILDING PERMIT APPLICATION 1
426 W. Cedar • PO. 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 INFOR TI CONTRACTOR IN ORM TION
Owner �3 i Company Name C-?/
Mailin Address a Mailin Address &Ixe7o�
City i� �StateA,Zip C de — City�A o�s� State l�� Zip Code 6Pho � 7Ot er P Phone -.�� -d//' Other Ph._
Lien/ itle 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 Water System Name of Water System
PARCEL INFOR ATI N - 1 Di it P cel Nov AO d Fire District
Legal Descriptio % o;
Site Address (Please jnclude street name, street ur�b� and c& ) i` �� S s
Directions to site IY� �f Abrti a2 4
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 > 15%
Is this permit submittal th 4result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB - New Add Alt Repair_ the P IMARY RESIDENCE ❑ SEASONAL ❑
Use of Building Describe Work —�
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 permis-
sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or t 9 work pro sed in e application, I have obtained permission from them to agply for this permit and conduct the work proposed.
x Date: f 3 d -2)
Owner/<bwers R e/Contractor (indicate which one)
FOR OFFICIAL USE BEYO T I P INT zJ`
Accepted b : Planning Pd Ck# Date Bid Pd Receipt No. `5/lJ l
DEPARTME L REVIEW APPROVED DENIED NOTES
Building Department p
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Buildinq Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee 426
Mechanical & Base fee Other AR ST:
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
MASON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION J
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 INFORMATIPV CONTRACTOR INJ~ORM TION
Owner '6�5�b//. / ?f- Company Name C-dZ S ,'I �,�,�'`/
Mailin Addres A �' !� *' �~ '` Mailing Address - Z'/fir 7f
City State 0ac_ Zip Code 2- City "N`-r i M'ne_a- State Zip Code) bs- .
b - r: 7.3 0 Phone 'c> - ' /!
Pho '� Ot er P ' Other Ph.
Lien itle Holder 2_- '? Contractor Reg. /arc F 2 +Q Exp. /:2
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 Water System Name of Water System
PARCEL INFOR ATION - 1 Di it P cel No, nl Fire District
Legal Descriptio 6, �
Site Address (Please)nclude street name, street urnkp,��r and ci y) Ai ,�
Directions to site .2fi>�`/ � AYfiJa�
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 th 2 result of a Stop Work Notice,Correction Notice or other enforcement action?Ye of
TYPE OF JOB - New Add Alt Repair other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building Describe Work 9 t t
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 permis-
sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion ort C5 work progoSed i5lhe application, I have obtained permission from them to a ply for this permit and conduct the work proposed.
X ' ' Date:
Owner/:owners RUpesenta0ve/Contractor (indicate which one)
FOR OFFICIAL USE BEYO T,�I i PINT
Accepted b Planning Pd Ck# Date i ' Bld Pd � Receipt No. k_. L
DEPARTME AL REVIEW AP VED .DE�dtEII-" NOTES
BuildingDepartment
Planning Department
Environmental Health Department .-
Public Works Department
Fire Marshal 1d
FEES
Building Permit Fee Site Ins ection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee -126 Mechanical & Base fee Other AR ST.
Wood/Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
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 INFORMATIOI)I CONTRACTOR INFORM4TION 1
Owner Company Name
Mailing Addresst r/R"� '& t' '' Mailing Address
City State '-: , Zip Code s City,-" f .;"t c.F State et-1 Zip Code/
Pho +� �`/ Other PF '-` ` ' Phone Other Ph. _
Lien! itle Holder `' '{ r �" �; ` "' j` ?�,, Contractor Reg.�I�`;WI F4 ?6% 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 Water System Name of Water System
PARCEL INFORMATION 1 Z Digit Parcel No. '' �� �. � Fire District
Legal Description' i° , 7" ' i s m. <S A =�� ,_iPA0,C; 14f.
Site Address (Please)nclude street name, street numb and city) w ? - i
Directions to siter �.,� - -r�' , ias ,°`�� ,� `T`c d +�f r r. �.� f R� .. , , c f f 't�'!F.; r.W
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 > 15%
Is this permit submittal th result of a Stop Work Notice,Correction Notice or other enforcement action?Yes,/No
TYPE OF JOB - New v Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building Describe Work
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 permis-
sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or the work progosed in.the application, I have obtained permission from them to al�iply for this permit and conduct the work proposed.
X_ a Date:
Owner/Owners Representative/Contractor (indicate which one)
r FOR OFFICIAL USE BEYO)r*PTHIS POINT -
Accepted Planning Pd Ck# Date t.�', ;' .Blcl Pd Receipt No
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department F1
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal VL
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee W
Plumbing & Base Fee Planninq Review Fee Js"
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
12/07/2003 22:06 5035432974 CUSTOM METAL FAB PAGE 01
45 P FUU1J L4U1kJMEN )
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0 X e' D Z'jF-.A' Pi4- oar'' -v"l ""vina, 7
�
HOOD DESIGN & SPECIFICATION FORM
0-ttC:k19 A-�� Pruicet Contact,-JLau4--
Jobbite Address: City, Zip Cude:_"�2b_
,'lumber of Clilss I Hoods on thin job:-.
Number off'lass 11 Hoods on this Job:
Yes
Drawing N11111hers Attached--
Artach Fan. Rood & Make-Up ��.ir Systenj Manufacturer Specificatifili Sheets.
Chiss I Hood Listing:
_Q i Item Model Size Due[ 'Foull Curb 0.L),
Amv- Number Manyfacturer Number U x W C.F.M. Size Static CFM
C010k,vto 1k;ry 4512-WP Is cl Il- q -get 7-41 6
Chiss 11 Flood Listing, Includes DislimacIline Pant Leg Systems:
Item Model size Duct Total Curb O.D.
QiAtv - Nuinbc-r MarrufAt tut Nwober .1, N' NN' C.FAI. Size $N16C CFNI Ohnensions
... .................
NIQICC-UPAir; Tempered? Yes_No_y_ 'I'Dtal Exhaust CFM--q1Z.
Make-Up Air Target 90% of Exhaust 87.1 (CFM)
Itein Model Duct Cull) O.D.
(Jury Number- Number Size Static CFrv1
ODD wa.
12/07/2003 22: 06 5035432974 CUSTOM METAL FAB PAGE 02
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