HomeMy WebLinkAboutCOM2009-00055 CANCELLED DUE TO INACTIVITY SEE LETTER - COM Inspections - 3/22/2010 ■
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.OAM AW9-QW5 S
PLEASE PRESS HARD BUILDING PERMIT APPLICATION Ary-)
426 W. Cedar-P.O. Box 186, Shelton,WA 98584
Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269 �C1� = �C
On the web www.co.mason.wa.us
APPLIC INFORMATION CONTRACTOR INFORMATION
Owner �L Company Name
Mailing Address = f Mailing Address
City n ion State Zip Code gr pTq Z- City State Zip Code
Phone 360 �qg- 31�'� Other Ph. L/!C G�a3-1 Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address E Mail Address
Drivers Lic.# m, NOOB Drivers Lic.# 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. - - Fire District 42
Legal Description
Site Address(Please include street name, street number and city) %5oZ L: _5t4 f 4 -- 166 u n"n ya 9
Directions to site
Will timber be cut and sold in parcel preparation?Yes/ b
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/
TYPE OF JOB - New Add Alt Repair.X Other PRIMARY�2ESII�ENCE ❑ SEASONAL ❑
Use of Building Acidjc. Describe Work ''-fir"-` U04.&< I c:,h.N aT=s T�r1
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 in 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 OFAPROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X_Q _, lL�s, r?�PufJ >z,4 7, Date: 5Ldo
Owner/Owners Representative/Contractor (indicate whic one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted b Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department f) Ito F5 002E
Environmental Health Department
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
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO0-A(Y laiO(��I • "� S
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
APPLICKI INFORMATION CONTRACTOR INFORMATION
Owner L�Lt= L_k1 c n4e,G—sl m ;u�"s Company Name
Mailing Address Mailing Address
j City U n%ate State Zip Code q 91 L- City State Zip Code
Phone3 ?�Lo if - 3 t� '�Other RO_/;Ph. 4 051 Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp. i
E mail address E Mail Address
i Drivers Lic.# p06 Drivers Lic.# DOB
SEPTIC /WATER SYSIE�M I� F� - Connect to New Septic Existing Septic
Connect to Water Syste444—rName of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address(Please include street name, street number and city) t U Q L~ .5ft It 4 /d G U n„ 14W
Directions to site
Will timber be cut and sold in parcel preparation?Yes
Is property within 200'of Saltwater �4 _Lake River/Creek ond
Wetland Seasonal Runoff Stream Slopes or Bluffs 15% ps
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/
TYPE OF JOB - New Add Alt Repairer Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Uset'fBuilding 19ri1j., �escribeWorkJ tf2lix- 1 t C.^IV 'ah- suonn �
-No. of Bedroom 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����. i
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocd%on.
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 der 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 across 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 OFAPROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION.
X 0 . Rn12tri., rh���, Date: S'fL�C9
' wner/Awt1stepresentative/Contractor indicate whiff one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted b Date
DEPARTMENTAL REVIEW APP DENIED / NOTES
Building Department
Planning Department Ito
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Z 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 4? Ems' Pre-Paid at Submittal
Valuation $ Gfj . TOTAL FEES
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO{_ i.,
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
APPLICK INFORMATION CONTRACTOR INFORMATION
Owner 1��k 0.0 Lj � r!% C, — Company Name
Mailing Address _" Mailing Address
-State Zip Code ' `+ City State Zip Code
Phone j6 c /2?- I 2, Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp. +
E mail address E Mail Address
Drivers Lic.# �,., b06 Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFPR, *0 N - Connect to New Septic Existing Septic
Connect to Water Systerf , Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. ••- % L- 7 7 Fire District
Legal Description
Site Address(Please include street name, street number and city) �• T& L:. /t � /
Directions to site
Will timber be cut and sold in parcel preparation?Yes/ To
Is property within 200'of Saltwater - 4 Lake River/Creek Pond
Wetland Seasonal Runoff Stream_Slopes or Bluffs
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 RESIDENCE ❑ SEASONAL ❑
h... / Describe Work a „k. t.__ r4 r ►
of Building � . —rr-
-No. of Bedroom 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/ N11A
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. 1 declare that I have obtained the permission from all
the necessary parties. If permission is required from any easement holder or any ether 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 OFAPROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X ," 3 / e a I# J ► ^.f Date: f!.�' 1
fi"
caner/Owners Representative/Contractor indicate wh;�one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department r '
PlanningDepartment
E;. fi ` i+'C - t ! �f 1' r;la„` ► {j i !t� ):.
Environmental Health Department
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
THIS PARCEL
INCLUDES
PLANS, BLUEPRINTS
OR. OVERSIZE
IMAGES
LARGE FORMAT
IMAGES HAVE , BEEN. STORED IN
FILE CABINETS) UNDER
PA RC EL N UMBER
PARCEL
CASE
# COM dDOq- D0055