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Fail Date Date one By Comme is (D (D C) Act, CCsss d b8 tof LJ5 _0 (D 0 (D 0 . .......... . FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO. PLEASE PRESS HARD BUILDING PERMIT APPLI ATION 426 W. Cedar • P.O. Box 186, Shelton, 7VA 98584 Shelton (360) 427-9670 • Belfair (360) 275-4467 Elma (360) 482-5269 On the web www.co.mason.wa us APPLICA j INFORMATION CONTRACTOR INFORM TION Owner Company Na - f C1G Mai lin Addres Rc1. Mailin Address $S 1 City r Stat&, Zip Code City ti� State_ Z p Code _ Phone- yah'`-10't Other Ph. Phone-14c,c � '(-�l01) Other h, Lien/Title Holder Contractor Re # F ��rb�_Exp. S- I-� E mail address E Mail Addres Drivers Lic. # DOB Drivers Lic.#_ DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. Fire Dilstrict Legal Description Site Address (Please include street name, street number and city) l �. Directions to site 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 ac ion?Ye No TYPE OF JOB - New Add Alt Repair k Other PRIMARY RE IDEN�E 2 EASO AL Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage 2nd Floorr 3rd Floor Basement Deck Covered Deck Other Sg.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 permis- sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica- tion or the ork proposed in t e application, I have obtained permission from them to apply for this permit and conduct the work proposed. X Date: Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date_ Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Ins ecti Plan Review Fee EH Review Fee PIumbin & Base Fee Planning Review Fee Mecha ,al & Base fee Other Wood /raas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEE � I ucHA TMENT OF COMMUNI Permft Fr oceaain ..-- T�DEVELOp NT Mason C gilnapeyylona/Addreg ounty Bldg. III 420 W.p�� ssin P.O, Box 186 8holton, WA 9e584 360( ) 427-9670 8elfalr (360) 275-446 Era (360) 482.5269 Sea - - NON-S-VRU -----=__- RE-RO N �NNI 0� _ Roof Slope: . Old Roof Material: New R00 f ing Mate ri Sheathing Underlayrnem: .# Existing Insulation New Inst dati0n: Roof Siope : LRC section R904.1 Roof slope cm-is t be indicated to e.ns ure selected roof covering is all vTd on des Roof Covering ; IRC section R905 tgaed pR� Selected roof coveriag rmut be installed in accordance man of a is s ecif i IPs p cauocu a.IId tila Qon : WSEC 10L3.2.5 cxcepti0n 2a.&2b C _ Existing roofs shall be insulaI;td to the requirtme s of this Code ' : a The roof uninsulated or insulation is b. All insulation in the roof/ removed to the level of the sheathing or,culrng PO` rns exterior to the s hen A-rzic Ventilation : LRCsection 806 Enclosed attic and rafts r area s LJl be s u 1/150 of the area of PPS wiz.h cross�venulatio The net area shaIl nos from u the space P be ventiLzted Lf 50% and not mo PPcx Portion,of the a ace to be ventilated, then 1/300 Ls has 80�0 of the ven La z s owed. �oPL,cant/Owner �' ti� Co ntra c C r Parcel No Permit NO, , Sigeaalre Date : ARC 10/19/04 a oo(iPPkuion.do ti I