HomeMy WebLinkAboutBLD Mobile Home - BLD Application - 2/25/2008 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
RECEIVED Shelton (360) 427- 6 0 - B web Ir w 360)275-4467 - Elma (360) 482-5269
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RMA 10 CONTRACTOR INFORMATION
Owner re 'Ill" hqrbarek Z j Gk Company Name
"• Mailing.Will ,A �'�' � Bo 9 Address
City ir State w Zip Code City State Zip Code
Phone, -.�75�8 oaf Other Ph-Z Q-&A0-78'3 _ Phone Other Ph.
Lien/Title Holde ameba-ct 4ov- Z c l� Contractor Reg. # Exp.
E mail address hQ z't k Qeop G.pG,Ly� E Mail Address
Drivers Lic. # C K 9 A4� GDOB -6 -53 Drivers Lic. # DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Wel — Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. /d D 7— 7,S- d0.1,T-0 Fire District a,
Legal Description Lo -2S '.r nc. r•a ekv
Sitrd�ress (P� �s In4l{�de street name, street number and city) O C LOr
Dir i r to siteIRI
r ►V
Will timber be cut and sold in parcel preparation?Yes No
Is property within 200' of Saltwater Lake River/ Creek Pond
Wetland v Seasonal Runoff Stream Slopes or Bluffs- %
Is this permit submittal the result of a Stop Work Notice, Correction Notice or other enforcement actin . Ye
TYPE OF JOB - New Add Alt Repair Other Y RESIDENCE X SEASONAL
Use of Building 89 P " nescrib�Work
No. of Bedrooms—L—No. of Bathrooms!g Square Footage - 1st Floor I ZX3(o 2nd Floor
3rd Floor Basement Deck Y..C.5 —Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make CQPfCfbk4odeI 7-rL- `L-t o0 Year172lp
Length—Width—Serial No.`V0G9,P3S�(pTG001PA No. of Bedrooms---�--No. of Bathrooms
Type of HeatY�/�Pu'''� Purchase Price $ ���OO°�- Replacement Unit? Yes/ No
Installer Name - V n � Iso w� Certification No. L�� 0 7�'/S
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 permission from all
the necessary parties. If permission is required from any easement holder or any other party in interest regarding this application or the work
proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the above
described property and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not comment within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANSO OGRESSINSPE N.INACTIVITYOF THIS PERMIT APPLICATION OF18 DAY WILL INVALIDATE THE APPLICATION.
X Date: ii� D
Owner/Owners Represe e/Contractor (indicate which one)
FOR OFFICIAL USE OND THIS POINT Accepted by.agnll Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department
Fire Marshal
FEES
Buildinq Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood / Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation S TOTAL FEES