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MASON COUNTY PERMIT NO„Id
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 FORMATION CONTRACTOR INFORMATION
Owner + +-✓`I7rNy Company Name_
mail in Address
Mailing Address
City lit a$t4te Zip Code — City.State Zip Code
Phone - Other P -�/ Phone Other Ph.
Lien/Tiitle Holder C- Contractor Reg. # Ex
E mail address C / p'
.r � .' Mail Address
Drivers Lic.If DOB - •F 23rlvers 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 Svstem 7r T t u
PARCEL INFORMATION- 12 Digit Parcel No_ I o�a, 3� , �b Fire District
Legal Description L)� /� /0 _R//& / } �/ / N , y Q
Site Address(Please irlgWde street name, street number an c )_ SZZ Al ,
Directions to site ffnl?i��p.,/F (� ( ���
azi t � i
Will timber be ut and Mid Id in pa el prepay tion? 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?Y o
TYPE OF JOB - New Add_ _,Alt_Repair_Other PRIMARY RESIDENCE
Use of Building- rj ' scribe Work ��a, �� SEASONAL ❑
No. of Bedrooms -- No. of'Bathrooms --� � �t
_Square Footage- 1 st Floor IA(Cx 2nd Floof
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - M ke Model
Length Width Serial No. Year_
No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price
Installer Name Replacement Unit? Yes/No
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 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 information
provided is accurate and grants employees of Mason County access to the above described property
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PROOF OF CONTINUATION F O IS BY MEANS OF A PROGRESS INSPECTION, ��and structure for review and inspection.
Owner/Owners Re resentauve/Contractorr indicate which one Date' `
FOR OFFICIAL USE BEYOND THIS POINT Accepted by' Lk l 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 Plannin Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES