HomeMy WebLinkAboutBLD2003-00341 - BLD Permit / Conditions - 3/28/2003 (5)PERMIT NO. BtD
MASON COUNTY
BUILDING PERMIT APPLICATION
CS W. CMS1P0. Elm SS. Slmwn, WAp86*I
Shelton MO) 4274570 Bela lsedl 27S4MT Elmo (3W14E04269 Seal* DOFI 404-0Y68
APPUCANT INFORMATION
Owner I
CONTRACTOR
Cantrettor Name
Mahn addtes3
Coy
INFORMATION
Melling Address
City Santa Zip Cade
SUM_ Zlp Code
_
Phone ( ) Other Ph. (__,J
Phone (
I Otter FT. LJ
Lbnilb /bider
Contractor Rog.
E mS Address
F ENO JJ
E-mail Address
SEP ICMAATER SYSTEM INFORMATION • Connect to New Sepik
System_ Name a Sewer System
E4gtg Sept
Calved b Saver
Wee
Was Saran
Nano of War System
PARCEL INFORMATION - 12 age Tax PacTel No. J
- Fee Dfetld
Legs Descrptcn
Sae Address (Please if ck.de street name, strew niWn and city)
Direction to site
--
We garter le cull end KM In parcel preparation? (Ye&Mo)
Seasonal Rash
SMN
Lake RlvorfCraek Pond Ward
Slops a Slugs
PERMANENT RESIDENCE CI SEASONAL RESIDENCE
TYPE OF JOB - New Add _M_ RepotOther Use of Suldng
Is des permed su*mjfal the IOWI of a Stop Work Nobs. Carnahan Naha a oter adwcememl action? (Yee/No)
Describe Work
No. cl Bewoao� No. of Bathrooms SQUARE FOOTAGE • 1N Row 3 P; r ad Flea
3rd Floor L _i ' Bann Oedk Ot iw e4 L
Garage Pasha Detailed CorPmn Abc/ed Detached
MOBILE HOME INFORMATION • Make Model
Length WMN Serial No. NO. of Bedroom No of Ballroom
Type of Hest Pecan Prize E Replesemeni Unit? (Ye&No)
betallr Non Cat$ldaeon No.
Model Year
NOTICE. TNS PERIT BECOMES NALi VOIO IF WORK 0RCONSTROCTION AOTIIDN?ED a NOT COaaeENCEb WITNN NO GAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR *SNCONED FOR A PERIOD OF Ile DAYS AT ANY Tat AFTER TIE WORK tS COIAAENCEO
PROOF OF CONTINUATION Of WON( S BY WEANS OF APPOOIESS INSPECTION. The on a awed an owners tree. mamas M re
rllnntrlan Pa1dessrxaras eV pens employees w Mean Canty eons b M sow dwauad p WsMand Sons Ia swear a heewron
Wl a PMa. Oenenth4w edmwdedgwF Deis= of nMPFre FbmdCn may remit in a Moo WA sew a path nwcatnn MAroWdprwa
a such N by Myrna Woe
OWNER AFFIDAVIT • I may nit I am exempt from M naaubaero of
the Cotner Repeoskon Law ILW 1027 and as. awe a me NW
cn roaoesrnereeb alit nt perms a Wed ere to a wet* Ee
r.a N arddwrwee Salt No apnea wlae to made Wvdme tat
r, nnnp sperm.
x
CONTRACTORS AFFIDAVIT- 1 artyta11 wnwr'wdy moans re •
aceeclw In re Sate W Wkanhelon aMM I am mere of re wdiwce
rpirwaNe reWeing the Welt 1w With the penile a awed end d
work shell be doe n eCniww a maewtr No noun MIS be lode
Meat Ent casinos approve
DIN .__ 'X Cale
Accepted by
FOR OFFICIAL USE BEYOND THIS POINT
Date Samna Account Due Recap No
DEPARTMENTAL REVIEW IAPPROVED
ISJIIa^a [lwpv-non:
Ooc Group Typo Cone
Penning Department
EmkopnlrW NesMt Opartrbni
RIMt Works Department
Fee Marshal
DINED
CONOMON ODDES
BWMIng Permit Fee
Ste Inspecton
Pan Reap Foe
EN Rewww An
i Sae Fee
Plelvag Review Fee
Plumbing
MMwicel A Base Fee
Otter
Woo60Y4eM Slone Fee
Side Fes
VMWbn Fee
RPPsd at Sabana
(
TOTAL FEES