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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 � W
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR ITFORMATION
Owner L.hI K ; + / Company Name
Mailing Address Mailing Address
City State " Zip Code ' "� City t State " " Zip Code
Phone Other Ph. Phone 5'3- Other Ph.
Lien/Title Holder Contractor Reg. *-` Exp.
E mail address E Mail Address
Drivers Lic. # DOB Drivers Lic. # DOB 't
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. ` Fire District
Legal Description
Site Address (Please include street name, street number and city) J '
Directions to site ;z j 4
Will timber be cut and sold in parcel preparation?Yes/ No
Is property within 200' of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs> 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building Describe Work - �f � -t1,= " F22 &'
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floo'- 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make 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.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below. I declare that I am the owner,owners legal representative, or the contractor. I further declare
that I am entitled to receive this permit and to do the work as proposed in the application. I declare that I have obtained the permission from all
the necessary parties. If permission is required from any easement holder or any other party in interest regarding this application or the work
proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the above
described property and structure for review and inspection. This permit/application becomes null &void if work or authorized construction is
not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANS OFAPROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION.
X Date: /
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department i d k (A -
Planning (AX-
Planning Department
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planninq Review Fee
Mechanical & Base fee Other
Wood /Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES