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FORM MUST BE COMPLETED IN INK PERMIT NO.: BLD C Gov T
PLEASE PRESS HARD MASON COUNTY
BUILDING PERMIT APPLICATION
4 ��
• 426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482 269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Ve i&cx et,.7Yt vf2 Contractor N ime
Mailing Address i -• Mailing Address
City Sh E?L to State .Zip Code q City State Zip Code
PhoneMja ) 27 -6 ether Ph.( ) Ph.( Other Ph.( )
Lien/Title Holder Contractor Reg. #
Address Expiration
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. LlgC) )S / 1 / C)C) Fire District
Legal Description F l O "
Site Address(Please include street name, street number and city) /d
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work /^e—
No. of Bedrooms 3 No. of Bathrooms 2— SQUARE FOOTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached_ Detached Carport 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-]certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I 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 ar proval.
X � % �G- Date �'" �-- X Date
�r FOR OFFII}C LOUSE BEYOND THIS POINT
Accepted by �-� Date I l.`, mittal Amount Due c5(n $� Receipt No.
aEPARTMENT'; R kEW APPROVEpPNIEp CONDITION COPES
Building Department
Occ Group str.
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
I
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Olumbing& Base Fee Planning Review Fee
-anical& Base Fee Other
-/Pellet Stove Fee State Fee
Pre-Paid at Submittal ( )
TOTAL FEES �'jCrr