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o CONCRETE MECHANI AL MANUFACTURED HOME,
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Date& Z5(o,4 B INSULATION Date By
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Date By Date j`&-j By S Date By
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Date jZ Q�� By S Date 1Z V7 Lx( By FNU> Date
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Groundwork Date 17-(CK1' 10(fBy 191
Date By WALLBOARD NAILING
D A V'V. Date " /-r D, By Ln&
Date (ZIP By f�L:� FINAL'I S E_CTIO
Water Line Date �� �( (� By/Z LS
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO. C�1" 66&))
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 NFORMATION \ CONTRACTOR INFORMATION
Owner Y�« .jCompany Name
Mailing Address 2 t 3 t 1 WICI f l" V„a. WS.Li o, Mailing Address
City _C�kt State�t� Zip Code ciSff City State Zip Code
Phone 2-06-9-z`f'�T3 Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address V .0 awei-L. t E Mail Address
Drivers Lic.# IAL,61 K6 (1-1 DOB 12 21- KS Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System ✓ Name of Water System LinaQd Cc GWI lOc.,..
Well Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. OD OC� Fire District
Legal Description c.,+n C ' ' C- W 7• .SL
Site Address (Please include street name, street number and city) .ACC- S_ t2► o L
Directions to site G< —r rcJA Wti
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% 11.E
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No. of Bathrooms I Square Footage - 1st Floor C�-7'5-
2nd Floor C/-4'L
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMA - 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 pecessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or the wo roposed ine.�=1' Ihe obtained permission from them to apply for this permit and conduct the work proposed.
X ( (/) Date:, - 2/ -0 y
Owner/Owners Representative/Cont or (indicate which one)
.FOR OFF A E BEYO T P INT I _
Accepted by' fanning Pd1� Ck# Date Bld Pd�eceipt No��
DEPARTMEN L REVIEW APPROVED DENIED NOTES
Building Department R 1200 a 0000 E
Planning Department
Environmental Health Department — P-0®;�' '00 4
Public Works Department T
Fire Marshal
FEES
Buildinq Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other rzC19 140 "—
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
F( RPM MUS`BE LETED IN INK MASON COUNTY PERMIT NO._ 66C
PLEASE PRESS HA 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 NFORMATION \ CONTRACTOR INFORMATION
Owner �� 5>C" Company Name
Mailing Address 2.t 311 ►MGt FI" V,,,). 6VS.Ij a Mailing Address
City --<::Q t State L,)cA- Zip Code GX I (.Ir City State Zip Code
Phone 2-o6- -(--79_Lj Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address V dc-I 0—Wei - l d.. E Mail Address
Drivers Lic.# 1.4 1 K if S 13 (1-( DOB 12-'L I- Y5 Drivers Lic.# DOB
SEPTIC/WATER SYSTEM I�tFORMATION - Connect to New Septic Existing Septic
Connect to Water System ✓ Name of Water System 17�dd Cc &AAA l.J, " („ " A
Well Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. 00 Oo Fire District
Legal Description t..v\ ' C_ W -7 .5 L
Site Address (Please include street name, street number and city) tAj:jr o
Directions to site Qns'r (Jl 4 1 Wti
Ld
Will timber be cut and sold in parcel preparation?Yes
Is property within 200'of Saltwater Lake River/Creek J!O Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% K_�p
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑
Use of Building Describe Work _
No.of Bedrooms�_No.of Bathrooms I Square Footage- 1st Floor 6_77 2nd Floor CLEFS_
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage �Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMA -'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.
OIMNER/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 ecessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or the wo roposed ine.�appli n, I have obtained permission from them to apply for this permit and conduct the work proposed.
X ( l/) Date:. �- 2/ y y
Owner/Owners Representative/Cont or (indicate which one)
,FOR OFF-ill A4 E BEYO T P INT i�'�• cif' ' C
Accepted by tanning Pd _Ck# _` Date Bld Pd eceipt No�� - 1�
DEPARTMEN'rAL REVIEW APPROVED DENIED NOTES
Building Department R 9 co 4 e e>O®o REGENEU
Planning Department
Environmental Health Department -- & .5W 200 j 960y
,36
Public Works Department 426 W_ CEDAR T
Fire Marshal
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
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
Owner Company Name
Mailing Address Mailing Address
City State Zip Code City State Zip Code
Phone Other Ph. Phone Other Ph.
Lien/Title 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 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/Na
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 PRIMARY RESIDENCE E]' SEASONAL ❑
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 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 enti4ed 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 proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed.
X Date:
Owner/Owners Representative/Contractor (indicate which one)
.FOR OFFICIAL USE BEYOND THIS POINT ',' � tl.
Accepted by:."' . ...planning Pd �`� ; - } Ck# ,d.`,` r' Date 't' ;. Bid Pd; f. Receipt Not_
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department ;,; ,..
Planning Department
Environmental Health Department r ' '-
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee 426 W. CEDAR ST;
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
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY PERMIT NO.:
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar/P.O.Box 186 Shelton,WA 98584
Shelton(360)427-9670 Belfair(360WS-4467 Elma(360)482-5269
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name c7 cam-�-
Mailing Address ? t �I t tM r I b� Q i G Mailing Address
City State ,� Zip Code_ R g-((._ City State Zip Code
Phone(Zc�S.) ?Ll 5 7-1 Other Ph.� Ph.(_� Other Ph.(
Lien/Title Holder v1 cSy�� Contractor Reg. #
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No. 2, 2- / / Q n o Q �� Fire District
Legal Description
Site Address(Please include street name,street number and city) VL O
Directions to site z 2
Is your property within 200'of the following: Body of Water(Name) Saltwater VW
Lake_ k River/Creek W Pond_ V.---> Wetland y�_O Seasonal Runoff VW Stream VU3
Slopes or Bluffs_ y�,p
TYPE OF JOB New Add Alt Repair Other Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Tyne of Fixture No.of Fixtures Fees LPG_ X Natural Gas Heatpump
Toilets _�_ Type of Unit No.of Units Fees
Bathroom Sink Furnace —
Bath Tubs n Heatpumps
Showers I Spot Vent Fan
Water Heater / Propane Tank
Clothes Washer �-- Gas Outlets
Kitchen Sinks If oo /Gas/Pellet tov
Dishwasher Kitchen Exhaust Ho� 1
Hosebibs �_ Dryer Vent
Other. ®tt"ier W"w
Base Fee L�D(� Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X Date '2(_G Cl X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
.... .
#7EPA#ZTMFA 05 :.it1^1/fEVlf AP,FROVE[):. pEfJIED Gi"fVRTT14?N:
Building Department
Occ Group Type Constr.
Planning Department
Other
426 W. CEDAR ST{
Other
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES
PERMIT NO.: G ,
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.
Shelton(360)27-9670/Beellf ir(3606�75467'Elma9360)482-5269
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name
Mailing Address Mailing Address
City State Zip Code City State Zip Code
Phone( Other Ph.( Ph.( Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No. / / Fire District
Legal Description
Site Address(Please include street name,street number and city)
Directions to site
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream
Slopes or Bluffs
TYPE OF JOB New ' Add Alt Repair Other Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures Fees LPG Natural Gas Heatpump
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps -
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer - Gas Outlets
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DL7ARTMENTAt;:REVIEVi/ APPROVED [JEIVIEf3 CQNRITIS3N.GQ[3t S
Building Department =
Occ Group Type Constr.
Planning Department R E C
EIVEn
Other
Other
A.
.;:.;:..;:.::. ...
PEES...... + ..
........._.................................._....................................._..........................................._._.......................................................................
..........._........
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee 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) 482-52 9
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Company Name
Mailing Address Mailing Address
City State Zip Code City State Zip Code
Phone Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic '"F 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 I
Site Address (Please include street name, street number and city)
Directions to site
Will timber be cut and sold in parcel preparation?Yes/' o
Is property within 200'of Saltwater r Lake River/Creeks' 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 RESIDENCE ❑'SEASONAL ❑
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms i 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.
OVVNER/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 entiked 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 wofrk proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed.
/ 4.
X ! Date:
Owner/Owners Representative/Contractor (indicate which one)
,FOR OFFIFJAL Y,$E BEYONQ THIS POINT.
Accepted by Planning Pd.A Ck# i Date Bld Pcf eceip t Noy.
i`ter- ) "
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department RECEIVED
Environmental Health Department ;f, ,r_ APR( ,} 15 20
04
Public Works Department
Fire Marshal 426 W. CEDAR Sfl,
FEES
Building Permit Fee S Site Inspection
Plan Review Fee ¢ 101 EH Review Fee
Plumbing & Base Fee Aa-2 ° + Planning Review Fee
Mechanical & Base fee -t //3. Other
Wood/Gas/Pellet Stove Fee State Fees
Violation Fee Pre-Paid at Submittal
Valuation $ &D TOTAL FEES
PERMIT NO.:
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION;
426 W.Cedar/P.O.Box 186 Shelton,WA 98584
Shelton(360)427-9670 Belfair(360)�75-4467 Elma(3601482-5269 4
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name
Mailing Address i Mailing Address
City State Zip Code City State Zip Code
Phone(__) Other Ph.C___) Ph.0 Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration
SEPTIC INFORMATION-Connect to New Septic -f` Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No. / / Fire District
Legal Description
Site Address(Please include street name,street number and city)
Directions to site
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream
Slopes or Bluffs
TYPE OF JOB New ,'Add Alt Repair Other Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures Fees LPG Natural Gas Heatpump
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps -
Showers Spot Vent Fan
Water Heater T_ Propane Tank
Clothes Washer i Gas Outlets _
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
i
)( Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTtUfENT1t:REVIE1Af APPROVED I3ENIEf} ONDiE101ti10
Building Department
Occ Group Type Constr.
Planning Department APH004
Other 426 W. CEDAR ST,
Other
E
.. .. ,.. ....... ....
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES
THIS PARCEL
INCLUDES
PLANS, BLUEPRINTS
O; R. OVERSIZE
IMAGES
LARG.E .FORMAT
IMAGES HAVE BEEN. STORED IN
FILE CAB' --INET(S) .UN DER
PARCE---L----N- -U-M,- -,BE--R---
PARCEL # 3zz33
CASE # So /
S�7c Y'
J
LC)CA OUST G
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Fo -:1 ) a 161 Ho me