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date date by Set Up
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date Floors Anal
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date by Walls FIRE DEPT.
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datebY
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date b Floors Final
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date by Walls FIRE DEPT.
PLUMBING date by date by
Groundwork Attic OTHER
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by
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03/15/99 MON 10:33 FAX 3604277798 MASON COUNTY BLD 3 C]wl4
' PERMIT NO.: 8L0 ` • ,
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY
BUIL ING PERMIT APPLICATION -3,
4 1 W.Cedar/P.O.Box 1E6,Shelton,WA 98584
Shelton(360)427-967 Beltair(360)279-4467.Elma(360)482.5269 Seattle(206)464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner 5PcFF'R71/, .J011A/ . Contractor Name jf.NK)
Mailing Address 3,54 .C/tic,-e,"C 74. ,0' Mailing Address
City P/,.tsa4,f0., State c4" Zip Code 251./496 City State Zip Code
Phone( 9d5)'/r7B777 Other, 1. 7 Ph.(____)7 Ph.(� , OtherPh.( J
Lien/Title Hold r foiriSa,� et• f„ --lc-, k Contractor Reg. #
Address ---F Expiration / _/
,
-ice � "
�EPTIC/WATER SYSTEM INFORMATION-Conned to New Septic Existing Septic Connect t��Sewer
System • Name of Sewer Sytem J Well Water System z/Name of
Water System_�'%»-t S/ e%'ok. Eve T fir
PARCEL INFORMAT1O -1 digit Tax Parcel No. "�`,3- 3 / 5c / cx��g Fire District
Legal Description Pot�� c4 R-e<fc1 %^<,<J4- 1.,/5 yr 96 . — {� �/�
Site Address(Please inc}l �de street named reet number and city) ?SIT %i ykar y /v °c.� .
Directions to site L1J�s7 5,dc ,4,^ a ,,,..„A /Vrar-A.0 t�' 1,1 e✓,c, /Pc_ <.'c. lob,— ZL . _
Will timber be cut and sold in parcel preparation? (Yes/No) AA? / , /,
Is your property within 200'of the following: Body of Water(Name) ,,ri c Coro el—eSaltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs , ,
TYPE OF JOB New d Alt I epair Other Use of Building Vacc a7`,'o s- AV -(
Describe Work /tJ s.1rs c- ''-c 16^s{A//s 10`A _ -
No.of Bedrooms No. of Bathrooms ..1. SQUARE F003AGE-1st FIoor1r)J,3 2nd Floor_.-0--
3rd Floor 1�-- Loft--re)-- Basement._Dec Other sq. ft.
Gara a A] Attached Detached Carport c., Attached Detached
MOBILE HOME INFORMATION-Make Model 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. .
r
r NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from tie requirements of Ilia CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 1827 and am aware of the ordinance contractor in the State of Washington and that lam aware of the ordinance
requirements for which this pemu:Es issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance No changes shall be made Without first obtaining shall be done in conformance therewith. No changes shall be made without
approval, , 11 obtaining approvaL .
X , 4+-.-/ F Date...3 A •-jJ X Date
FOR OFFICIAL USE BEYOND THIS POINT •
Accepted by Date Submittal Amount Due Receipt No.
,
14. ii, ,2-3 = G31ii s- 1
2$.- •
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pLun eta b= 73 t2,° = �3 • ?.T •
yy.'s f.zz=I;G•
/tt�r H = (.. uE,I,.r7AL Fee 4Z4.. 40)
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