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(a C n Cll 0 CD cr a — o a 3 0 `CD < O `< O 0 S (D a CD n a)CD m -0 00 o F. (0n CD CD -0 0 N p 0 a- 0) (T 3 C K cn CD =s'_0 a_ < N � 3 0. r cn cD a. a CD D Q (D 0 C X 0 CD o O" a 0' C -0 "D — (D o (D 0 �' =' 0 C cr Q-0 �_ n C C 7 O N CA) �' O (D 0 O O 0 -0 (a O < v 1 O (On o Q 0 0 G o cn m m a -h 3 O CD p -� o .moo _0 CD CD W CD 0 CD cn CDCD v CD D co �' o << 3 0 � a � y I o s00 7 { & so \ 2 / \ § \ \ \\ \ / / > ( = m ° = 8 \ \ / \ \ / = a o = ; = - m § 8 & . = e & \ / + + ^2_0 e \ § E t0 £ o ^ � z � \ / \ $ 0 \ k = g | ƒ { § \ \ 2 / 7 & § D 0� cl � - 2 = \ z ± M j \ / 8 / § 03 E § CD . \ \ CD- 0 ° _ i Zn \ } 3 \ m / #f \ \ cn D8 \ � o 94 0 \ \ \ \ ƒ � M ) j M e % E m = = R /\ / / CD \ \ \ \ ag \ / , _ 3 m 0 % ) \ $ ƒ _ � / � � A \ § a \ / o ( \ \ a ® E \ § m CD PD o � mo & ESE MASON COUNTY PERMIT No. BUILDING PERMIT APP CATION 426 W. Cedar • FO. Box 186, Shelto WA 98584 Shelton (360) 427-9670 • Belfair (360) 275-446 Elma (360) 482-5269 On the web www.co.mason.wo.us APPLICANT INFORMATION CONTRAC R INFORMATION Owner U16 ,LLO '� Company Name Mailing Address !0 ] Mailing Add ss City �jj�'1 UA State ) Zip Code City State Zip Code Phone 7`t C6 O her Ph. Phone Other Ph. Lien/Title Holder ��^' Contractor g. # Exp. E mail address E Mail Addr s Drivers Lic.# DOB Drivers Lic. DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic E isting Septic Connect to Water System Name of Water System 'I 0Db � Well Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. f ` G Fire District Legal Description Site Address (Please include street n street number and city) 6 E7— ? A) Directions to sitef Will timber be cut and sold in parcel prepafatio►� /No Is property within 200'of Saltwater Lake 4)(7 River/Creek Pond Wetland Seasonal Runoff Stream ' ' Slopes or B ffs 1 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New_ A d Alt _ Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑ Use of Building cribe Work No. of Bedrooms No. of B throomsSquare Footage - 1st Flo i 2nd Floor 3rd Floor Basement N Deck Covered Deck Other Sq.ft. Garage Attached etc Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No.of edrooms No. of Bathrooms Type of Heat Purchase Price $ Rep acement Unit? Yes/ No Installer Name Ce ification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permt �J Acknowledgement of such is by signature below.I declare that I am the owner,ownerslegal representative,or the ontrac or.Tf Ur declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I ff� e the permis- sion from all the necessary parties.If permission is required from any easement holder or any other party in intere g1 dnapplica- tion or the work proposed in the application, I have obtained permission from them to apply for this permit am ct the wor p oposed. Date: D I • CEDAR ST. X Owner/Owners Representative/Contractor (indicate which one) - FOR OFFICIAL USE BEYOND Th IS POINT Accepted by: Planning I'd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW i APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee W Site Ins a ion Plan Review Fee EH Review Fee Plumbing & Base Fee `�� Planning view Fee Mechanical & Base fee C0 Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid 41 Submittal Valuation $ TOTAL F S lqwll�-- 91 ..................................... c � ._., cn 2m o -1 z r z cmz n o cn c f � d 1 0m 0 C c; :0 o z � soz : > `� PERMIT NO.: FORM MUST BE COMPLETED IN I K MASON COUNTY PLEASE PRESS HARD PLUMBING/MECHANICAL PER 'IT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-t467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFO MATZO CONTRACTOR INFORMATION Owner d AJ Nb �'t Contractor Name Mailing Address -0- 10-7 Mailing Ad ess City S*EL.`i� State Zip Code City State Zip Code Phone too ) S�6(o ther Ph.(� ) 7© S'71,�= Ph. Other Ph. Lien/Title Holder Contractor eg. # Address Expiration SEPTIC INFORMATION-Connect t&New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION- 12 digit Tax Parcel No. ( .c.%f., Fire District f Legal Description I V A44tu site Address (Please include street name,street number and city oDjU Directions to site N R1v Is your property within 200'of the following: Body of Water(Name) _ Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs 7E OF JOB New TYPE of Fixture Add Alt Repair Other Use of Building s/Units 1st Floor 2nd Floora_Basement Garage Closet PLUMBING FIXTURES (Show 9umber of each) MECHANICAL UNITS Fuel Type: Electric Type of Fixture ND-QLFEb=DA LPG Natural Gas Heatpump Toilets Iy Furnace ace of nit No.of Units Fps Bathroom Sink Bath Tubs Heatpu s Showers Spot Ve I Fan Water Heater T Propan ank Clothes Washer a Gas Ou l is Kitchen Sinks Wood/Gas/Pellet Stove Kitchen Exhaust Hood Dishwasher Dryer Vent �c Hosebibs Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT. I THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF UCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYSAT ANYTIME AFTER THE WORK IS COMMENCED. OF CONTINUATION OF ORK IS BY MEANS OF A PROGRESS INSPECTION. he owner or agent on owner's behalf,represents that the ion provided is accurate and grants employees of Mason County access tot above described property and structures for review and on of this project. Ackn wledgment of such is by signature below: AFFIDAVIT-I certify that I m exempt from the requirements of the CONTRAC R'S AFFIDAVIT-I certify that I a currently registered as a or Registration Law RCW 8.27 and am aware of the ordinance contractor in he State of Washington and that am aware of the ordinance ents for which this permit is issued and that all work will be done in requirement regulating the work for which this ermit is issued and all work nce therewith, No changes shall be made without first obtaining shall be don'. in conformance therewith. No ch nges shall be made without approval. first obtainiryg approval. �( Date X Date FOR OFFICIAL USE BEYON THIS POINT Accepted by Date Submittal Amo' nt Due Receipt No. ;:<:<:;::I'7.t"1!A#t1`MEN``AEz:#2t1I#EW::>«:;:;;;>;;;:::<•»:r.>::.:Al?#':.f3��t�C>!:::>:.::::q�htlEt3:::::::.:;;:<,:;.::::;;;:::;;;:.:::::>:::::.::;:.:>::. Building Department Occ Grou T e constr. Planning Department Other Other .::::::::::::::::::::::::.............................. Permit Fee Site Plan Review Fee UFC Plan Revie i Fee Plumbing&Base Fee Other -hanicai&Base Fee Other Pre-Paid at Sub ittal Inspection was/Pellet Stove Fee -ee TOTAL FEES