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SUN cot,
MASON COUNTY Permit No: �d
(,
a DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING•PLANNING•FIRE MARSHAL (360) 427-9670 Shelton ext. 352
http://www.co-mason.wa.us/community-Ae—vZ (360) 275-4467 elfair ext. 352
�ss4 426 W Cedar Street, Shelton WA 98584 (360) 482-5269 HIma xt. 352
a BUILDING PERMIT APPLICATION -�—�
PROPERTY OWNER INFORMATION• CONTRACTOR INFORMA E1 V LA-1;
NAME r6U p NAME: 52015
MAILING ADDRESS: r 2 MAILING ADDRESS:
CITY;�/(/�7�JU STATE:. 3IA ZIP: CITY: STATE: 4 4 EDAR 51
PHONE:, CELL: �U PHONE: CELL:_
EMAIL:, x� p6"f � EMAIL :
a 0 P1 L&I REG# E .
CONTACT :
OWNER CONTRACTOR ❑ BELOW ❑
NAME: -/ N l MAILING AD SS:/�' ), I Z-
CTTY elrz- j�,i STATE: ZIl' PHONE: CELL:
EMAIL,: .e-:�.
PARCEL INFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) `A 9,CXA - 2_-4 -00(Y)C_," FIRE DISTRJCT LP
LEGAL DESCRIPTION(AB REVIATED :
SITE ADDRESS - CITY
DIRECTIONS TO SITE ADDRESS
IS PROPERTY WITHIN 200 FT:
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF STREAM❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GREATER THAN 14% YES NO ❑
TYPE OF JOB: NEW ADDITION ❑ /ALTERATION ❑ REPAIR❑ OTHER ❑ /
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) ,/ � �e�//✓��'� l,L.�c �� '' z-4 1 r'1
IS USE: PRIMARY ❑ SEASONAL❑' NUMBER OF BEDROOMS NUMBER OF BATHROOMS
DESCRIBE WORK
SQUARE FOOTAGE:
1ST FLOOR sq.ft. 2ND FLOOR sq. ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq. ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. ATTACHED ❑ DETACHED ❑ CARPORT sq.ft. ATTACHED ❑ DETACHED ❑
MANUFAC -D-HOMEINF *4 COP OF THE FLOOR PLAN
"`REQUIRED
MODEL LENGJ—-~—
DTa— BEDROOMS BATHS Y S L NUMBER
OWNER acknowledges that submission of inaccurate information may result in a stop work order or p rmit revocation.
Acknowledgement of such is by signature below. I declare that I am the own r or owner's legal repres ntative. I further
declare that I am entitled to receive this permit and to do the work as propo d. I have obtained permi sion from all the
necessary parties, including any easement holder or parties of interest reg ing this project. The own r or legal
representative, represents that the information provided is accurate and grar is employees of Mason County access to
the above described property and structure(s)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 OF INSPECTION' INACTIVITY OF THIS PERMIT
APPLICATION OF 180 DAY WILL CAUSE THE APPLICATION TO BE PIRED. ASON OUNTY CODE 14.08.42)
Signature of OWNER Date
DEPARTMENTAL REVIEW APPROVE DATE DENIED DATE TAGS/NOTES/CONDITIONS
1 -
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL • c -
FEE'S TOTAL VALUATION:
BUILDING PERMIT FEE FIRE ACCESS AND GRADE
PLAN REVIEW GEO-TECH VIEW
PLUMBING&BASE FEE STORMWATER.REVIEW
MECHANICAL&BASE FEE TOTAL ES
WOOD/GAS/PELLET STOVE VIOLATION IVESTIGATION FEE
PLANNING REVIEW FEE VIOLATION F OF,
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