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CONCRETE MECHANICAL MANUFACTURED HOME��
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Footings / Setbacks Date By Ribbons
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Foundation Walls Date B y Se r— t-up
Date By INSULATION Date By
B G / Slab Insulation Floors Final
Date By Date By Date By
FRAMING Walls FIRE DEPT
Date By Date By Date By
PLUMBING Attic OTHER
Groundwork Date By
Date By WALLBOARD NAILING
D.W.V. Date By
Date By FINAL INSPECTION
Water Line Date !1-z/ os
Date By
�,ii��is Date By
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PERMIT NO.: BLD
MASON COUNTY
BUILDING PERMIT APP (CATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482 5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACT R INFORMATION
Owner f- LJ1S Contractor t , me
Mailing Address Mailing Address
City State , Zip Code cjS k City State Zip Code
Phone(_) Other Ph.( ) Ph.( Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration
ESEPTICIWATERINFORMATION-Connect SYSTEM INFORMATION Connect to New Septic Existing Septic Connect to Sewer
Name of Sewer System Well Water System Name of
ystem
PARCEL INFORMATION-12 dligit Tax Parcel No. 0 t, Fire District
Legal Description i -, -.
Site Address(Please include st eet name, street number and city) D '
Directions to site r-n '-f � - 1 _a
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 Rur off Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st FIDOr 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
GaraLe Attached Detached Carport Attache _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 qo.
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 A T 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 a ove described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I 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 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 qonformance therewith. No changes shall be made without
approval. first obtaining approval,
X' f Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENT UI SO
Building
Department
Occ T1
e CoVt1r.li/0
/
Planning Department
Environmental Health Department
Public Works Department
i
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee Planning Review F 'e
Mechanical& Base Fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submitt I ( )
TOTAL FEES