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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons 0-
date by Gas Piping date �ZZ �/g b
Foundation Walls date by Set Up
date by INSULATION date '� �� by�1
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEFT.
date by date by date by
PLUMBING - OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date b date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date by
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date FRAMING
by date by date by
Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date _by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date FRAMING
by date by date by
Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
GroundworkAttic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by I date by
FORM MUST BE COMPLETED IN INK PERMIT NO.. BLD
PLEASE PRESS HARD MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275•d467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner I 1 1, A
P R Contractor Name
Mailin Address A)6 O A Mailing Address
City State WA Zip Code City State Zip Code
Phone(2/4� ) Other Ph.( j Ph.( Other Ph,(�
Lien/Title Holder iX 09/77 #/E,qT—f/z�LMR ontractor Reg. #
Address �f}�� Expiration
SEPTIC/WATER SYSTEM INFORMATION-Conn Existing Septic Connect to Sewer
System Name of Sewer System �Jll ilial T-0AJ/ Well it.� Water System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No. 4Q,402 P,9,J50 Fire District�1_
Legal Description "' �eJ NI�J L u)P Al AA)6 cj
Site Address(Please include street name street number and city) lug cA� ' //Jl+ EJTD
Directions to site A1,IAT-H lel c Fr 4) ld.Z Y a r RA ) AJc p 5 1-+
Will"timber be cut and sold in parcel pr paration? (Yes/No) AJy
Is your property within 200' of the following: Body of Water (Name) NLI --Saltwater—
Lake if d
Ad River/Creek OJd Pond�_Wetland � Seasonal Runoff 041 Stream r0 LLI
Bluffs NY H
13
TYPE OF JOB New Add Alt Repair Other Use of ilding gom
Describe Work p6,.,E lµaHc' 1ti'�c��ctru�rD r7c)
No. of Bedrooms_3No. of Bathrooms SQUARE FOOTAGE-1st Floori&off 2nd FloPHRIASSISIANCE EW
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model 11RUCTTE Model Year q4'
Length d/ Width W 9 Serial No. T02 d/Z6 P• No. of Bedrooms �No. of Bathrooms_ Z
Type of Heat !C LccT2[C- Purchase Price $ A v, e` ReXa cement Unit ?(Yes/No) Al d
Installer Name G
" 6 / _7
Certification No. LU'AA1 S Osk G�"
Surf C
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-1 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 e without first obtaining shall be done in conformance therewith No changes shall be made without
approval. / first obtaining approval.
a2z Date
FOR FFICIAL U E BEYOND THIS POINTED
Accepted by Date / Submittal Amount Due R eipt No.
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODU
Building Department NO 6-AJ F �;aI n I !O ►O to Do-
Occ GroupT e constr. SQ 3 U
Planning Department
Environmental Health Department
Public Works Department
f
Fire Marshal
Valuation $
FEES
Building Permit Fee �O 00 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
..............:..........................:...........
.:..:::.::::::.::.::•.;:.:::.:;:::::::::::::::::::::::::::::::.>;:>;:<.;:<.;:.::..::.:::. TOTAL FEES
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