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Date By ,, Water tine FINALINSP G I Date By Date Date By ID Type of Insp. Pass/Fail Request Date Inspect.Date -Done By Comments 0 3 o � 1rGc.� � 1 t�UIP I dl� �� r •'Q / ca '/�'4/ t 9 W n v N CD o cn n - v o N 0 T a m 1 0 1 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NOS/ 0117 11.1 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 INFORMATION CONTRACTOR INFORMATION Owner .j t SC(ZoC,c, Company Name MCMGU- Cis) Mailing Address P-011114C 421 Mailing Address P.v. r'�)C ?aZf City I 7Aytut_) State U-'A Zip Code v CitYC_-%,V.04.0,A State L4_.A Zip CodegYS°-7 Phone 025 _2v(,1"3 Other Ph. Phone --3�L) 1 Other Ph. Lien/Title Holder Contractor Reg.#Mt-,Mt C-J�t)440CExp. /-cit-, 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 - 12 Digit Parcel No. Fire District Legal Description Site Address (Please include street name, street number and city) W-51 G h—It I o to Directions to siteTFJML-tzz-Y­ Ur,:ian: :�j ►Ac1--0u412A>-Z-,CjL Will timber be cut and sold -el preparation?Yes Is property within 200'o Saltwa 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 JOB - New Add Alt Repair Other PRIMARY`[ t� NC EASONAL ❑ Use of Building Describe Work No.of Bedrooms No.of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOM INFORMATION - Make Model Year Length Width Serial No. No.o rooms No.of Bathrooms Type of Hea Purchase Price$ Rep1acement Unit? Yes/No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit rev bon.Ac nt of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare � d 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 I �t�xxsssswn is required from any easement holder or any other party in interest regarding this application or the work proposed in t4 I' ti 1 have obtained permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,I information provi is accurate and grants employees of Mason County access to the above described property and structure for review and i Z PR OF NU N OF ORK IS BY MEANS OF A PROGRESS INSPECTION. X Date: Owner/Ownersr Representative/Contractor indicate which one F R 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 Building Permit Fee Site Ins ection 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 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 OwnertC. Company Name ` , Mailing Address .. �� =�`I Mailing Address City i State 4� � Zip Code %'' � _= City _ �.: State C . Zip Code Phone `= Lif -a Other Ph. Phone - (_. Other Ph. Lien/Title Holder Contractor Reg.#:`_ i k 44 t:'cExp. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic existing Septic t- '- Connect to Water System Name of Water System Well Water System :: Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. "=2'sr - %_ ,r:_. Fire District Legal Description Site Address (Please include street name, street number and city) r i Directions to site = 'k-: ': , Will timber be cut and sold in parcel preparation?Yes f.N 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 JOB - New Add Alt Repair Other'i"' t_ PRIMARY RESIDENCE'[4-SEASONAL ❑ Use of Building Describe Work 'r""�_ ".I `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 HOM INFORMATION - Make Model Year Length Width Serial No. No.o rooms No.of Bathrooms Type of Heat Purchase Price$ Re aaement Unit? Yes/ No Installer Name Certific OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work o jr vocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the cont I further d Ibr 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 perms i fr II a necessary parties.If permission is required from any easement holder or any other parry in interest regarding this application q§t work pro s�e application,I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or ar4t%p oyy�ers be 1,represents that the information provided is accurate and grants employees of Mason County access to the above described propeq-96awkure for review and inspection. PROOF OF QQNTINU N OFPORK IS BY MEANS OF A PROGRESS INSPECTION. Sj- X ,.; _ / r f2 Date: Owe/Ownersf Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department i tM i Planning Department 5111105 Environmental Health Department Public Works Department Fire Marshal f FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview 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 e 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 ip IC Company Name Mailing Address B-'.0 =t- Mailing Address 4� -r i v.,a City; J=���• . State � �" Zip Code �`" "`�`� Cit Y State Zip�Ty,Pf,, � P Code Phone i'r" � ,% Other Ph. Phone _ Other Ph. Lien/Title Holder Contractor Reg. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic 'xisting Septic L-'_ 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 sold in parcel preparation?Yes/,N9> Is property within 200'of Saltwater Lake River/Creek Pond Wetland SeasonalRunoff 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 :_ e 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.off"rooms No.of Bathrooms Type of Heat r Purchase Price $ Reptacement Unit? Yes/No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order on�fev�e ion Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further d�l�a{{eC�tli t titled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all ecessary r s.If permission is required from any easement holder or any other party in interest regarding this application or the work pro. i thkaApl' I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,re re that the information provided is accurate and grants employees of Mason County access to the above described property an4ft f(x review and inspection. PROOFOF GQrjTINUATIGN OF)NORK IS BY MEANS OF A PROGRESS INSPECTION. `EDAR S7„, X ;'��.-�: (r. Date: I. Owner/Owner4Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department l Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee A/0 Pre-Paid at Submittal Valuation $ Lf 3 . Z TOTAL FEES o� p,A-rca,1 � 3�3a-SD- 1Og03 n2 � L '•.pep\ ^rD �._. • _ 0 u .............................................• ,N ®`'ORE �o�k„k rf S t wdZQz_ N IV G �Y-_,• ,--F.- ,__._..• ,. •. _—,7"co�___- _F FAR FS 0/4 "e ra p°' m s f g QRC4 v Xz s c a rf ®•COp-`CAlCO cX �'FI-,� •� - 7 COMP.CSEPT�� r.",.::.K - --- P lIt 2. A t E R Y c� m o,:A n Z Y N � - EP , Al --. . - - - FP F i --Ar TOP / x A