HomeMy WebLinkAboutBLD20000-01336 REROOF - BLD Permit / Conditions - 10/16/2000 mW
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3WOH 3I180W IVOINVH03W 313HON00
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77
PERMIT NO.: BLD h
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5 I69 Seattle 206 464-6968
APPLICANT INFORMATION, CONTRACTOR INFORMATION 1.
Owner Contractor N e
Mailing Add ess Mailing Addre s
City €'/7Z� ; State ILZ p Code �, ( City State Zip Code
Phone( /) (16'11�,* Other Ph.( Ph.L Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic isting Septic Connect to Sewer
System Name of Sewer System ell Water System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No. OO U/ G' 3 / Fire District
Legal Description
Site Address(Please include street name, street number and city)
Directions to site . ' ► / ►,n i e-44ep 6 f`
a L
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 Run ff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt Repair Other Use f Building o
Describe Work t
No. of Bedrooms 1,. No. of Bathrooms_L SQUARE FOOTAGE-1st F oor 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 AUTHOR ZED 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 WOR14 IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behj lf,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-1 certify that I am exempt from the requirements of the CONTRACTOR' 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 tate 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 reg lating 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 nformance therewith. No changes shall be made without
approval , first obtaining apr roval.
X Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
#7Ef' 1RTNI;ENTA1, E�!«VII»W. APPRQVED p NIE#� CONDITION CODES
.__ ... _ .... ........ __... _.. _.
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee Planning Review File
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submi al ( )
TOTAL FEES