HomeMy WebLinkAboutBLD2005-01626 Final on Expired Permit - BLD Application - 9/15/2005 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
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
APPLICANT INFORMATLON CONTRACTOR INFORMATION
Owne Mi(:,hoel 4- 1 roLct "-s. I a—y— Company Name
Mailin AdAws§ Y L Mailing Address
'City t State I Zip Code City State Zip Code
Phone 211101� Other Ph.AeL1 .1IL) I36 C Phone Other Ph.
Lien/Title Holder - ti Contractor Reg.# Exp.
E mail address - IkMlecitue.(iTM1 E Mail Address
Drivers Lic.# g 1;--j!q - kpn Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic =xisting Septic
Connect to Water System Name of Water System
Well Water System Name of Water System
PARCEL INFORMATION- 12 Digit Parcel No. Fire District
Legal Description
Site Address (Please include street name, street number and city) `
Directions to site
Will timber be cut and solq in parcel preparation?Yes/N
Is property within 200'of SXjtwater Lake River/Creek Pond
Wetland Seasdna unoff 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 IP MAR E I ENCIT SEASONAL ❑
Use of Building Describe Work- 1")A "" tit e l'�Yl
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 application,I have ed
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,repre ra,M4_tC.j ion
provided is accurate and grants employees of Mason County access to the above described property and structure for revi and inspection.
SOOF O CONTINUATIO F RK IS BY EA�N ,OF A PROGRESS INSPECTION.
�C -� Date -/�'-
Owner/Owners Re rese ative/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
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