HomeMy WebLinkAboutBLD2006-00586 Cancelled MH Space 18 - BLD Application - 4/10/2006 AM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
LEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar • RO. 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
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner- i1c'-Ct -L r�J�S�'► 4$r!-�� Company Name K�Ks Ke�i�t �{o►,.t S p
Mailing Address �-l$� / � 1 Mailing Address 16S01 4 vim.
City ` State W►4 Zip Code City State h1-A Zip Code%-;Sl
Phony 36o M-��l�3 Other P 3�t 11_1-iloS C�-l/ Phone �S3-3S 1 --OS^So Other Ph.
Lien/Title Holder Contractor Reg.#KC4SM4_Q1? ,,5 Exp. -7 /3-D6
E mail address E Mail Address
Drivers Lic.# DOB /a Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Sep Existing Septic
Connect to Water System A Name of Water System A .44 jle/
Well Water System Name of Water System �r
PARCEL INFORMATION - 12 Digit Parcel No. 34�L3a— so: '`473co/ Fire District
Legal Description
Site Address (Please includ street } e, street ni r a d city) 7 E S�- fQ 4
Directions to site , d V, � c- ob�`!.� �er�.�c`
Will timber be cut and sold in parcel prep ration. Yes N l�
Is property within 200'of Saltwater Lake o River/Cr k Pond N
Wetland o Seasonal Runoff o Stream Slopes lu 15%
Is this permit submittal the result of a Stop Work Notice,Correc N other enforcement action?Ye o
TYPE OF JOB - New Add Alt Repairer Other PRIMARY RESIDENCE ® SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms 4- : Square st Floor /o 9) 2nd Floor
3rd Floor Basement Deck! r Co red ck Other Sq.ft.
Garage Attached Detack,d rt Attached Detached
MANUFACTURED HOME INFORMATION,'' a � Model `f�� Year
y Length�0 Widt g'�erial No. �auJ No.of Bedrooms o.of Bathrooms 2
Type of Heat Purch se Pri $ Replacement Unit? Yes/No I
Installer Name �-�- Certification No. W y , go 3 g p
OWNER/BUILDER Acknowledges submission o accura ation may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the ner,owne gal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the ap ation.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any othe arty in interest regarding this application or the work proposed in the application, I have obtained
permission from them to apply for this permit conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees ojfAason County access to the above described property and structure for review and inspection.
PROOF OF CONTINUATION OF WORK I Y MEAN OF A PROGRESS INSPECTION.
X
Own r Hers R te ich one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Buildinq 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