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1P CD gs Date X
CD Footings I Setbacks Gas Piping By Ribbons 0
CD Intenor Date BY interior-Date By Date By
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19 B�44 Exterior-Date set-up
Point Load f Isolated Footings INSULA-ndN Date By
BIG I SLAB INSULATION .............................. -- 0
FIRE DEPARTMENT
Date BY
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F-- Aatiwn all% Floors Date Y 0
Date BY Data By - DECKS
FRAMING Walls Date By
Date By Data By - PROPANE TANKS
Vault Date By
MBING PLU� Date By OTHER
Gate
Attic ou. Type-
ate B y Date y
D Date By
D.W.1v DRYWALL Type-
Int.Brace Wall Date By
Date By Dal By
FINAL INSPECTION
Water Line Fire Separation
CIO Q
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6 Q
Pass or Request Inspect. 0
0 Fail Date Date Done By Comments -4
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PERMIT NO.: BLD
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
TTT Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR IN R ATION
Owner 2 Contractor Name ,U+ •rt v�` t �•
Mailing Address 230 LJ, PIAIE 046eE.S "(I Mailing Address 3 R'
City.,►r' State L&W Zip Code City D i, State J&Zolf Zip Code fl.T-1 3_
Phone(,Sltd )l/'32- 54/2 Other Ph.(____) /pge.ZOther Ph.0
Lien/Title Holder 6.4mk Contractor Reg. #Tow
Address it Expiration pdl/ ?0_/
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
PARCEL INFORMATION-12 digit Tax Parcel No. ®Q a / �j / Q'l.�Gt. C, Fire District
Legal Description CT & NW 1 ,t :2 P 0- Al ii A,16* eJ
Site Address(Please include street name,street number and city) ell A-
Directions to site—AJDA70 101 . Ta RAJ LefT
4 e F'�oAf flWriC A r G &A BiNq J A A51 4er
Will timber be cut and sold in parcel pr paration? (Yes/No)
Is your property within 200' of the following: Body of Water (Name) Alo Saltwater Atd
Lake ° River/Creek ,`::• Pond J Wetland V Seasonal Runoff ,✓d Stream AJ& Slopes or
Bluffs 'I-
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work
No. of Bedrooms No. of Bathrooms SQUA FOOTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Dec Other sq. ft.
Garage Attached Detached Carpo 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-I 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 made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X d l rR Get✓ y to ✓ f�i' , X Date
FOR OFFICIAL USE BEYOND THIS POINT
f
Accepted by -: Datg1� ubmittal Amount Due � '(j Receipt No.
1 '�1U
DBPARTMENTAI» REVIEW APPRovI-*D DENIED CONDITJON COQES
Building Department W ST (of-ipl <0N
Occ GroupType Constr. IN 12-tS S
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
300�5• -- s'b
Valuation $ �E'Z X ►Z' 6� = 13 8 g
FEg
Building Permit Fee g. ZS' Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Other T . Fc(,, T U
Wood/Gas/Pellet Stove Fee Other
Violation Fee Pre-Paid at Submittal ( tO y. B y )
TOTAL FEES
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7!77ttt
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