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PERMIT NO.. BLD�
MASON COUNTY
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 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name
Mailing Address Mailing Address
City State Zip Code City State Zip Code
Phone(____) Other Ph.( ) Ph.( Other Ph.( )
Lien/Title Holder Contractor Reg. #
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System Name of Sewer System Well Water System Name of
Water System t j.irrr _
PARCEL INFORMATION-12 digit Tax Parcel No. !,/;l;po7 1 /&.o&yn Fire District
Legal Description ,: Al ll
Site Address(Please include street name, street number and city)
_14;1 Acts
Directions to site p� ,. )/� �( / 4
1 lee
4iIl?imb4 be cut and sold in parcel preparation? (Yes/No) 4&
Is your property within 200' of the following: Body of Water (Name) &0 Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work ck it
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport 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.
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-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X `"" Date - X Date
L FOR OFFICIAL USE BEYOND THIS POINT
w Accepted by �'' Date—z _ Submittal Amount Due 1Q Receipt.,No.
DEPARTMENTAL REVIEW APPROVED pt~NIED' CONDITIONeap :
_-.
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
Valuation $
FENS
Building Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Other
Wood/Gas/Pellet Stove Fee Other
Violation Fee Pre-Paid at Submittal ( )
TO TALFEES
77,77
MASON COUNTY PROJECT SITE INFORMATION
Case No.
Name PARCEL NUMBER Date
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
Names of Fronting Streets Septic System
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line.
adjacent property line-> , I E-adjacent property line
, I
Fri
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" I I
I
I I
17 65
4.
� .
I
I
f I
h
I
adjacent property line I .a,�/ �r I Fad'acent ro ert line
SAMPLE SITE PLAN try
adja�nt property line-> 3zO� _ _ _ E-adjacent property line
I p 30-
.SEASaw/AL _k`PT7L_ I
.�" FtOM6 I ,Gn6.tn1
PrioPos�n saps:c
1
I R I
VAGn,T I T rtAees
I 30 j
i
I(� D0.oPosCD 50"
I \ PL RiC LLLTUR L A I
\\ T I /
1 I ,
/oo'
I � I
I i
x� /00' —� I
R I '�
11
A I
adjacent property lined ; A"• \i <-adjacent ro ert' line
TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.)
"^ SAMPLE TOPOGRAPHY PROFILE
dts+ar.ce. to
Shru.Lt(.�Y�
di8't'ar�Ge. *�
Slopm t-o¢
dis�anaa
40 �
Signature Date