HomeMy WebLinkAboutBLD2013-00413 Bulkhead Repair - BLD Permit / Conditions - 7/12/2013 \ � � b - - - -
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Date By Data By PROPANETANKS
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Date By OTHER
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.aI� 61 Pti 60 I �7
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
• n, �, `° 426 W. Cedar• P.O. Box 186, Shelton, WA 98584 "Jr
i�o : r d ` Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269 l I ^rl
On the web www.co.mason.wa.us 7 N
APPLICANT INFORMATION / CONTRACTOR INFORMATION
Owner l<.- F M r;- i l hl r n e n E A. ,I Company Name L,i,.15 r,a c
Mailing Address 31-1C 7 1I.I-n.1 A✓e S Mailing Address 3 i ✓A "IF 7rd� / %Qti'e
City ed5lt�'?L, Statel-6 Zip Code 2""2-� City r A H LA 1,-�A State ILI Zip Code - Tbf
Phone z 3 �1.7/3733 Other Ph. ,)S31- 2o l`iS�`/ Phone 3 E e "73l 3G13 Other Ph..2;3z7 3i
L-is4 Title Holder i2,Inc. f ,TPA,, P,r ✓Al lnr Al Contractor Reg. # Exp. _
E mail address Mc„'�:> '� /fyY9�-11t5/+. /l7rl E Mail Address �« + -ands a
Drivers Lic. #/ r,-n t,-b y Zzc�✓ DOB 7_-/ -S3 Drivers Lic.# ran l l 3_f";etL DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. 3 L z 3 -1 - 3 -1 - 07 3=7 Fire District
Legal Description Zy - a7--3 irA t IAA t CGr<. vn,f . LcY3� i7-
Site Address(Please include street name, street number and city) 3�' c S/z / e,
Directions to site /l r r J aT. a r ( f+ /lJ /. : ,A
l2r s r . �r
e*rl E Sid 7 -!•� � 3 u / ItL" cA/h,;) -lr,
Will timber be cut and sold in parcel preparation?Yes (�,O
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs /o
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_ Repairer Other PRIMARY RE$IDENCE ❑ $EA•O$ NqL 0
Use of Building Describe Work Fl, ✓� > 3 fr, > cFle� h,:/iL,.a.� / del tAli
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. 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 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 and structure for review and inspection.This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY
MEANSOFAPRO tySryECTION.INACTIVITYOFTHISPERMITAPPLICATIONOF180DAYSWILLINVALIDATETHEAPPLICATION.
X c t-n Date: / -_ - /3
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEY014D THIS POINT Accepted by Date
DEPARTMENTAL REVIEW ' APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department n
Fire Marshal
FEES
Building Permit Fee Site Inspection
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
/aluation $ TOTAL FEES
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.Bij r96i h— e)O� 192
PLEASE PRESS HARD BUILDING PERMIT APPLICATION )
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 T1 rl'Jr
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269 /1 I�
On the web www.co.mason.wa.us A
APPLICANT INFORMATION - CONTRACTOR INFORMATION
Owner ��l>�= F M r,- / �h1�•nen �A- I Company Name
Mailing Address 3 L1 C 7 i;� J h% 5 + Mailing Address 3 z-I ✓ a 7c, 5;d� .L r4n e
City PJ, / L�' tate I�'2 Zip Code "7-� City r A H LA �A State _ +(_1 Zip Code - '3
Phone 2 ' 35
-127 3733 OtherPh. -� -3 F- 7o 2`J31 Phone 3cn 731 �6 '/3 Other Ph..2s3z/c �a3t
L-ieal Title Holder i,t• +; r! D . j/1? rn e Contractor Reg. # Exp.
Emailaddress �� +✓� re /f , Y9C" /11511. crrr� E Mail Address r, dsca „cam N/,c
Drivers Lic.#/I „- r, b y zzcn/ DOB ?_-1 —� Drivers Lic.# r ij? ld 3 L DOB 'L
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. 3 a 2 3 -1 - v - 7, a a n Fire District
Legal Description Z t- v-�-- 3r Tr A c -t
Site Address (Please include street name, street number and city) `� c c S/Z / C r ✓.o r
Directions to site fl r c. / Fi' C:N ' l /rld.r' _ .:', k ! F S + • /[ In /1na_ie t p e 1. S f <. R k,./ r
/[� 3 4 ;., / %[�_ cFlh;n ,nLr,'c a✓. /,. /</1e .-rr' ! /a;.i
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 7 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_ Repairer Other PRIMARY RE$gIDENCE ❑ $E,4SONrL 0
Use of Building Describe Work LI I-ee,�9 tr,' 3 f,e< 3 c -le< ,lk,<r ( . + r, r;T- i
No. of Bedrooms No. of Bathrooms Square Foota i 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 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 and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY
MEANS OFA PRO CTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPL(CATION.
X Date: 13
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department 4G
Environmental Health Department OD
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
/aluation $ TOTAL FEES
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