HomeMy WebLinkAboutCOM2009-00009 Cancelled ATF Patch Roof and Replace Windows - COM Application - 1/29/2003 FORM MUST BE COMPLETFU IN iN, MASON COUNTY PERMIT NO'C
PLEASE PRESS HARD BUILDING PERMIT APPLICATION �
Bcc zoo-0�or.� �Ma � - ov���
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
Owner 011�v j - Iil4�s ��tre�c��s' _ Contractor Name
Mailing Address 'a.� : � 5c) Mailing Address
City State Z Code _ City _ State Zip Code
Phone (3Go ) �7S9313 Other h. (, c'j ) -��s'y Phone (__) Other Ph. ( )
Lien /Title Holder Contractor Reg. # Exp.
Email Address Email Address
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic A—
Connect to Sewer System Name of Sewer System
Well �` _Water System Name of Water System
PARCEL INFORMATION - 12 digit Tax Parcel No. 32-2.2- '52- 0 Fire District
Legal Description
Site Address (Please include street name, street number and city) hS7r 1 A; lje jz "' J
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No) A.1
Is property located within 200' of saltwater y-- Lake River/ Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs
PERMANENT RESIDENCE ❑ SEASONAL RESIDENCE ❑
TYPE OF JOB - New Add Alt Repair Other Use of Building
Is this permit submittal the result of Stop Work Notice, Correction Notice or other enforcement action? (Yes/No)
Describe Work e
No. of Bedrooms No. of Bathrooms ' QUAR- FOOTAGE 1st Floor 2nd Floor
3rd Floor Loft basement f D ck Other sq. ft.
Garage Attached Detached ` Carp rt Attached _ Detached
MANUFACTURED HOME INFORMATION - Make Model _Model Year
Length Width Se r � No. of Bedrooms No. of Bathrooms
Type of Heat Purrcch e Prig $ Replacement Unit? (Yes/No)
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMESVEHARUE
WOR OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN
180 DAYS OR IF CONSTRUCTION W DED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER
THE WORK IS COMME D. PROINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. THE
OWNER OR AGENT ON OW R'S BESENTS THAT THE INFORMATION PROVIDED IS ACCURATE AND GRANTS
EMPLOYEES OF Mason COUN AE ABOVE DESCRIBED PROPERTY AND STRUCTURES FOR REVIEW AND
INSPECTION OF THIS PROJECT. ER ACKNOWLEDGES SUBMISSION OF INACCURATE INFORMATION MAY
RESULT IN A STOP WORK ORDER EVOCATION. ACKNOWLEDGEMENT OF SUCH IS BY SIGNATURE BELOW:
OWNER AFFIDAVIT- I certify that I am exempt from the require- CONTRACTOR'S AFFIDAVIT - I certify that I am currently regis-
ment of the Contractor Registration Law RCW 18.27 and am aware tered as a contractor in the State of Washington and that I am aware
of the ordinance requirements for which this permit is issued and of the ordinance requirements regulating the work for which this
that all work will be done in conformance therewith. No changes permit is issued and all work shall be done in conformance there-
shall be ma'f`e without first obt�initig approval with. No changes shall be made without first obtaining approval.
rl'41 _ X Date _
Date
FOR OFFICIAL USE BEYOND THIS POINT 'j'AN 2 '29
Accepted by (� Planning Pd
Date Z q��"I Bid Pd. _ Reciept No. � LI`` `i `I��
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES`
Building Department 1� D�
Occ GroupType Constr. �J
Planning Department
Environmental Health Department
Public Works Department
[TTeMarshal
Valuation $
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
TOTAL FEES