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Date By Data By PROPANE TANKS Q°
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Date By OTHER M
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Date BY Date B Date By
y FINAL INSPECTION c
Water Line Fire Seperation p
Date By Date By Date By w
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Type of Insp. Fail Date Date Done By Comments
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO. (�Qnj42LdLI'�� �
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
UN1'l YYI�t' 426 W. Cedar• P.O. Box 186, Shelton, WA 98584
(-"�'�-'�Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
j c'�Ctz_'� cu-% I I'1(- On the web www.co.mason.wa.us
APPLIC T INFORMATION n CONTRACTOR INFORMATION
Owner -f Company Name
Mailiinddress Mailing Address
City' State j,0 AA Zip CodeEJF-2 `_' City S t Zip Code
Phones - Other Ph. Phone Other Ph.
Fit� er Contractor Reg. # Exp.
E Mail Address
Drivers Lic. # DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System l
Well Sewer System Name of Sewer System oV(
PARCEL INFORMAT�N - 12 Digit-Parcel No. ' T.
Fire District
Legal Description I �-
Site Address (Please include street am street number and city) n
Directions to site /-- L-- �t D Uu',
r.
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 JO$-r New yid AltOther E ❑-seAse AL ❑Use of Building L�a� (.2� nescrib�RLg�ai�
No. of Bedroom No. of Bathrooms Square Footage- 1 st Floor 2nd Floors
3rd Floor Basement Deck— Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
A ACTUR OME INFO TION - Make . rModel o
Year
eiaen Wdt Sr No of B roo s Bathroo
yp eat chase P e $ RC aceme Uni / N
11 tificatoI s r e 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 obtained permission from them to apply for this permit and conduct the work proposed. The owner or
agent on owners behalf, represents that the informaticn provided is accurate and grants employees of Mason County access to the above
described property and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANS OFAPROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF IEP DAY§WILL INVALIDATE THEAPPLICATION.
X Date:
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Datev� I O
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department --
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Ins ection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Plannin Review Fee
Mechanical & Base fee Other
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 INFORMATION CONTRACTOR INFORMATION
sa {' Company Name
Owner .�.��.I�, �,, :.r- !�� -:� ��_ t �� ,.
MailinAddress I '' _ -4 Mailing Address
City State Code City Stga Zip Code
Phone
Other Ph. Phone . Other Ph.
Liery Tttie++o ier Contractor Reg. # �',x Exp.
E-mail-add r E Mail Address
Drivw&,.jr.:,#, - Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION 12 Digit Parcel No. ` _. +''- a c", Fire District
Legal Description .- > i<
Site Address (Please include street name;street number and city) ` A,. - t�Jt7 1 y '
Directions to site " x / t L t ' f` � t tJ,
Will timber be cut and sold in parcel preparation?Yes/,Ao,'
Is property within 200' of Saltwater t.•,.,f Lake River/Creek Pond
Wetland Seasonal Runoff i' 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 - New Add Alt Repair Other___^_; P•R fSlBfi�EE ❑'S�`ASE�fdflt ❑
Use of Building Describe Work �`,. . < is <* '. .! = Y: l �_i sr :�s • a` /c� ,�
No. of Bedrooms, No. of Bathrooms Square Footage- 1 st Floor 2nd Floor.1.
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUfACTUREd"HOME INFORMATION - Make Model Year
Length `T-Width Serial.No. 4No. of 1306ro8ms ` No of Bathrocros
Typ e of F�eeat Purchase Price $ Replacement,Unit? Yes/ No,,
Irist�iller Name Certfication hio
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 easernent 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 informaticn provided is accurate and grants employees of Mason County access to the above
described property and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANS OFA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF,lap DAY$WILL INVALIDATE THE APPLICATION.
X .Date:
Owner/Owners Representative/Contractor (indicate which one) 1 }
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date - o
DEPARTMENTAL REVIEW APPRAVEq DENIED ! NOTES
Building Department
Planning Department '
Environmental Health 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 / da Pre-Paid at Submittal
Valuation $ p TOTAL FEES