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Date By D.W.V DRYWALL Type- -0 Date 8y Int Brace Wall pate By W Date By FINAL INSPECTION Water lane Fire Sepe ration N m @ Data By Date By Date By o m V s Pass or Request Inspect. c TYPE cif Insp. Fail Date Date Done By Comments co o � 0 CD O n O 7 Q O 7 N O S N (D 3 N (fl (D 0 i coPpt`y_ MASON COUNTY COMMUNITY SERVICES1�, _,�� L PERMIT ASSISTANCE CENTER: Permit No. .BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL 615 W.Alder Street,Shelton,WA 98584 RECEIVED l Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone �8sd Belfaic(360)275-4467•Phone Elma:(360)482-5269 SEP 3 2011 BUILDING PERMIT APPLICATION 615 W Alder Street PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: r'��� S ` NAME: MAILING ADDRESS: 42 C e IQ 3f MAILING ADDRESS: CITY: 6 e 1 (r--,r STATE:L,1 ZIP: O S- v CITY: STATE: ZIP: PHONE#1: 3 k, © Z 7 5-- -5'.S c,' PHONE: CELL: 3 6 O 5--0 7 14 1 PHONE#2: EMAIL : EMAIL: 10, _ edM L&I REG# EXP. PRIMARY CONTACT: OWNER ❑ COINTIRACTOR❑ OTHER Chi t ti.�er NAME ar t C� r h Q>�r► !t EMAIL ►� �c{ • v� MAILING ADDRESS Ft V t v 1/61 3 CITY t "t 1^ STATE PHONE 3L o CELL PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) II Z 23 --- 10 6}Z1(D ZONING "s LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT SITE ADDRESS 5-6 D EA S-}' c r v t 5 t Z e v+ d CITY DIRECTIONS TO SITE ADDRESS 1'V o - 4 E'cx s o h 6, goy I??`�W►-V L.o 0 b b� TA 1Le- IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO❑ IS PROPERTY ITHIN 200 FT OF THE FOLLOWING: (Check all that apply): SALTWATER LAKE❑ RIVER/CREEK❑ POND❑ WETLAND ❑ SEASONAL RUNOFF❑ STREAM ❑ TYPE OF WORK: NEW$ ADDITION ❑ ALTpERATIJDN❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) R 1 r t y �/�+ 1S u I O r `5 '"r t ve wK IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS HEATED STRUCTURE? YES(Whole Bldg) __[I YES(Part[s]of Bldg) NO❑DESCRIBE WORK �ee�L.. 12 o c e C�r.c►-�.�P '3(0Z Zt4�i�t,w•�S ty^113 -Coy L SOUARE FOOTAGE: (propose+existing) 1 ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq. ft. DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft. GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑ MANUFACTURED HME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* KE ODEL WIDTH BEDROOMS BATHS SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC ❑ SEWER❑ / NEW❑ EXISTING ❑ PLUMBING IN STRUCTURE? YES ❑ NO❑ If yes, attach completed Water Adequacy Form PERIMETERNOUNDATION DRAINS PROPOSED? YES ❑ NO[] EXISTING SQ.FT. EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS OWNER acknowledges that 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 and I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal representative,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s)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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42) X ,401%7 ature of O R(Must be signed by the OWNER I Date DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT ,vl PLANNING DEPARTMENT . t!�I1/G FIRE MARSHAL PUBLIC HEALTH