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HomeMy WebLinkAboutBLD2004-00684 MFG Home - BLD Permit / Conditions - 5/7/2004 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 APPLIC T NFORMA N CONTRACTOR INPRMATIO Owner Company Name E�Pr" l`enn nc, Mailin Add s Mailing Address Cit State f�_Zip Code City State Zip Code Phone 0 1 E Other Ph. Phone Other Ph. Lien/Title Holdero- Contractor Reg. Exp. - =Q E mail addres E Mail Address Drivers Lic.# DOB - Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Exi tin ptic Connect to Water System Name of Water System Well Water System Name of Water S stem PARCEL INFORMATION - 12/Digit Parcel o. Fire District Legal Description•S Site Address (Please include street Amp. street number and city)''` Directions to site Will timber be cut and sold in parcel preparation?Yes No 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?Ye o TYPE OF JOB��-"�New���—Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑ Use of Building L11�iFIJJV - Describe Work No.of Bedrooms No. of Bathrooms Square Footage- Vst Floo 2nd FI aw-Floor Base, RnT' Deccj � CovereL4Wc'r Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HO E INFORMATION - Make Model Year�1 Length _Width Serial No. No.of Bedrooms No.of Bathrooms Type of Heat Purchas Price $ Q° Replacement Unit?�es 1No 44 Installer Name Certification No. &ls sa OMVER/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 WI the necessary parties.If permission is required from any easement holder or any other party in interest tion or thdpooK proposed in t application,I ha obtained permission from them to apply for this permit and cond��� Date: �' 7— O 7 2004 Owner'/Owners epresentative/Contractor (indicate which one) MAY O FOR OFFICIAL USE BEYONDTHIS POINT 426 W. CEDAR STJ Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. i DEPARTMENTAL REVIEW APPROV D DENIED NOTES Building Department O � Planning Department Environmental Health Department Public Works Department Fire Marshal rJ 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 Pre-Paid at Submittal /Valuation $ TOTAL FEES MASON COUNTY PERMIT NO. � - BUILDING PERMIT APPLICATION � w " 426 W. Cedar - P.O. Box 186, Shelton, WA 98584 Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269 n_ On the web www.co.mason.wa.us APPLIC"-iii,INFORMATION CONTRACTOR INFORMATION Owner' , '" Q , : - Company Name{ Mailing Address '`fit �i �. ; y , ;. t' Mailing Address City State =? Zip Code / <� City State Zip Code P.jione { 1 , Other Ph. Phone Other Ph. Lien/Ti#I&Holder `/r Contractor Reg.#; �,�� 4 D.1 Exp. E mail address E Mail Address Drivers Lic.# s DOB I f.. 1 ; Drivers Lic.# ty 't1;�,�}- . > ,`-a , DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System „ W�11_"_--_Water.System Name of Water System PARCEL-INFORMATION - 1 Z Digit Parcel No- ' � " Fire District Legal Descriptio � � r � ': � w ' v - "' Site Address (Please include street riame, street number and city) �v- ` 4-1 - Directions to site c Will timber be cut and sold in parcel preparation?Yes(fV 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?Ye TYPE OF JOB - New Add Alt Repair Other4 PRIMARY RESIDENCE SEA NAL ❑ Use of Building Describe Work-x't' a 40 4 wrf i/*ram No.of Bedrooms=—No.of Bathrooms _Square Footage - d'st Floor 7.3 a 2nd Floor"f 3.rd-Fl6or Baset nt' Deck -- " Coverej.&� Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model � �, •:�z _ .._Ye ar_LL:4 Length Width —Serial No No.of Bedrooms m�No.of Bathrooms _ Type of Heat Purchase Price $ _ -" Replacement Unit? YdsY 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 t ' rmis- sion from all the necessary parties.If permission is required from any easement holder or any other party in interr"Ir t fGsWplica- tion or the work proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed. `,, �__ Date: - �`. �,� MAY 0 7 2004.1 Owner/Owriers Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT 425W. Accepted by: Planning Pd Ck# Date Bld Pd :Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES ' Building Permit Fee Site Inspection -7 ©p 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 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 a Elma (360) 482-5269 On the web www.co.mason.wa.us APPLIC T NFORMA I N CONTRACTOR INPORMATIOR Owner Company Name �fr 1"`0r"1)0C,k Mailin Addr s Mailing Address_ •Y &- Cit Stat t ' Zip Code City State Zip Code Phone 1 Other Ph. Phone Other Ph. Lien/Title Holder Contractor Reg. ` Exp. 'n E mail addres E Mail Addres, Drivers Lic.# DOB Drivers Lic.# D h a DOB SEPTIC/WATER SYSTEM INFORMATION - Connect_W New Septic EX* " ptic Connect to Water System Name of Water System Well Water System Name of Water S stem PARCEL INFORMATION - 12 Digit Parcel o. Fire District — i Legal Descriptions ' Site Address (Please include street me, street number and city) 0 Directions to site Will timber be cut and sold in parcel preparation?Yes No 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?Ye o TYPE OF JOB - New Add Alt Repair Other PRY ARY RESIDENCE SEASONAL ❑ Use of Building- Describe Work Oki No.of Bedrooms 0_No.of Bathrooms I Square Footage- Vst Floo 2nd FI 3x*floor Bas Dec � Covere 4m-c� Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HP ME INFORMATION - e Model year�q Length4�A idth Serial No. No.of Bedrooms '�► No.of Bathrooms Type of Heat Purchas Price$ r Replacement Unit? es 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 f' " r c n declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have ot � sion from Al the necessary parties.If permission is required from any easement holder or any other party in interest reg g his applica- tion or the)Pork propospd in th'application,I hra�ye obtained permission from them to apply for this permit and conduct th- LuuT X rkdrr i Date: 17 HI I Owner/Owners Aepresentative/Contractor (indicate which one) A76 W. CEDAR FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department a; ,y, '7 -•' 1/ d I Planning Department , =- t/t / _ :'`c` i Y EEnvironmental Health Department Public Works Department j f' Fire Marshal FEES Building Permit Fee 77, Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee Planning Review Fee `J• i Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES t 41 t NouS pkep �I iA*- I t � _ t � �a�N�'ac.�'itrrcl Herne- � Gi � v --- — --- --- - - - - 'o i Q 7o• hark prl've wa y Al, APPROVED RECEIVED MASON COUNTY DCD PLANNING SITE PLAN REQUIRED TO BE ON SITE PLANNINCMAY 0 7 2004 CHANGES SUBJECT TO APPROVAL 426 W. 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