HomeMy WebLinkAboutCOM2014-00099 CONNEX - COM Application - 6/30/2014 COLS? MASON COUNTY PERMIT NO. m_/-0
Y: DEPARTMENT OF COMMUNITY DEVELOPMENT d
E i BUILDING•PLANNING•FIRE MARSHAL + `
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
_ Mason County Bldg. 111,426 West Cedar Street (360)275-4467 Belfair ext. 352
PO Box 279, Shelton,WA 98584 (360)482-5269 Elma ext.352
BUILDING PERMIT APPLICATION
ONVN'ER INFORMATION: CONTRACTOR INFORMATION:
NAME:�t 1��'Tf.J�`f .y` /�1 NAME:
MAILING ADDRESS:69 MAILING ADDRESS:
CITY:a-- 0)9' STATE: U..) ZIP: CITY: STATE: ZIP:
PHONE: CELL PHONE: CELL:
EMAIL: txv EMAIL,
L&I REG# EXP.
PARCEL IWFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) FIRE DISTRICT
LEGAL DESCRIPTION(ABBREVIATED) :
SITE ADDRESS /O60 Fc-zzs—G- CITY I`�GJ �
DIRECTIONS TO SITE ADDRESS
IS PROPERTY WITHIINT 200 FT:
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND In TLAND ❑ SEASONAL RUNOFF❑ STREAM ❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THEJECT-GREATER THAN 14% YES❑ NO.V
TYPE OF JOB: NTEW ❑ ADDITION ❑ ALTERATION REPAIR❑ OTHER ❑
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) S
IS USE: PRIMARY ❑ SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
DESCRIBE WORK
SQUARE FOOTAGE:
1ST FLOOR sq. ft. 2'-NID FLOOR sq. ft. 3RD FLOO sq.ft. BASEMENT sq_ft.
DECK sq. fL COVERED DECK sq.ft.STORAGE sq.ft. OTHER sq. ft.
GARAGE sq.ft. ATTACHED ❑ DETACHED ❑ CARPORT sq.ft_ ATTACHED ❑ DETACHED ❑
MANUFACTURED HOME E'FOIRA'IATION: x4 COPIE OF T4 FLOOR PLAN
MAKE MODEL YE r LENGTH
WIDTH BEDROOMS BATHS SE E
OWNER/BUILDER acknowledges submission of inaccurate information may result in a st -Fvork order or permit revocation.
Acknowledgement of such is by signature below_ I declare that I am the owner, owners leg sentative, or contractor. I further
declare that I am entitled to receive this permit and to do the work as proposed. I have obtaine er tssion from all the necessary
parties, including any easement holder or parties of interest regarding this project.The owner dr au 'rued agent represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structure(s)for
review insp ction.This permit/application becomes null&void if work or authorized constru i is not commenced within 180
days or cons ction rk is spended for a period of 180 days. PROOF OF CONTINUATIO OF IS �Y MEANS OF
INSPEC { IN T THIS ERMIT APPLICATION OF 180 DAYS WILL INVALIQAiTe PPLICATION.
X � �, 30i 17
Si ature o'A licant Date _
OWN / REPRE E CONTRACTOR
Print Name CWW ATE) V
DEP_4RTMENT.4-L REVIEW APPROVED DATE DEIFIED DATE TAGS/NOTES/COIN'DITIONS f
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
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