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' 1 FORM MUST BE COMPLETED IN INK MASON COUNTY PLEASE PRESS HARD BUILDING PERMIT APPLICATION 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269 On the web www.co.mason.w i.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner `' 1 Ccaa Company Na a C_ARG.T11. CowsrAuc r-roN 4L4 Mailin Addr ss I Lc4dlae Mailing Addr ss ').rjo PERses N6 cT Cit A C State I KA-Zip Code C K3 City .5 ELr N State w A- Zip Code 9 9S8y Phone t 1� -C-1 -1 l�� Ot er Ph�C'.t1�4CIC�-t I i 3t I Phone_ 2!0-11 _ Other Ph.aco-Y'1*-oioB Lien/Title Holden 4'k' ij' T (-An Contractor Reg.41CAR61c L9SI Bu Exp. 1/31/07 E mail addresses C. • ' E Mail Addre 3s_H egoq 10a a aol• cewf Drivers Lic. NLS61 l� cl P r DOB 1 t1-:D!3-- (c=1 Drivers Lic.# it 6.r1 E 31 o R DOB t119/y7 SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic X Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. q 3,e t x (,,cc F Fire District il Legal Description Site Address (Please include street name, street number and city) I v E %4 oop LAOD PKXYt Directions to site W0,00LAND rse eFF E47V)4 Spit4,NbS Rex$. Will timber be cut and sold in parcel preparation?Yes/ 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 action?Ye TYPE OF JOB - New Add AltAW Repair_,Other PRIMARY RE IDENCE [& SEASONAL ❑ Use of Building Describe Work REPLACE RX741404 i r N c sNE7 S EPtACE t ew No.of BedroomsNo.of Bathrooms Square ootage!1 s I or""I 3 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.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 Cert fication No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a sto work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the c)ntractor.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 pe mission from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this application or tie 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. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X Date o S Owner wners Representative ntracto indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Ins ect on Plan Review Fee EH Review Fee Plumbina & Base Fee Planning Review Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee T Pre-Paid at Submittal Valuation $ TOTAL FEE' nt X t s` `_ > oY1 44 Cl h err - u d .10 ID rri to ti � y QQ s tmn T 10ST OR— In MAI it Fri IT I � ` I ? s p I f r a; A 1 ` �j O r t C h vI z o y o Q c Z i r m buN r C yr ► t^ ` S D A M ?� c ti *n mrn ti '4 ti r°l 3 z sr6AA6t w�5HJiLV�S c 1 o�^ I h NA 17 f o �• > c r 1 , i , I Ck R.. .a m a r' r 4 , : 0� r T w 1