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Box 186, Shelto 1, WA 98584 Shelton (360) 427-9670 • Belfair(360) 275-446 I- Elma (360) 482-5269 On the Web www.co.mason. a.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner ;I� 'n 00'7"H y M,WA ,s'kk Contractor Name Mailing Address YA-, ' „ lyi /?Y ,,5= Mailing ddress City State State Zip Code �' �' City State Zip Code Phone ('SIaD A•Y4&Other Ph. ( ) Phone ( ) Other Ph. ( ) Lien/Title Holder Contractor Reg. # Exp. Email Address Email Address SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System Well Water System� Name of Water System 4,j_ p PARCEL INFORMATION - 12 digit Tax Parcel No. 5420 jj't�/ / QQB/ -- Fire District Legal Description t ll. ' Site Address (Please include street name, street number and city) Directions to site Will timber be cut and sold in parcel preparation? (Yes/No) 420 Is property located within 200' of saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or bluffs PERMANENT RESIDENCE 0 SEASONAL RESIDENCE ❑ TYPE OF JOB - New Add Alt Repair Ot ier Use of Building Is this permit submittal the result of a Stop Work Notice, Correction Notic r other enforcement action? (Yes/N.o J6 Describe Work /¢ " f 0 710, f ,,y, i No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE - 1st Floor 2nd Floor 3rd Floor Loft Basement Deck Other sq. ft. Garage Attached 4 Detached Carport Attached Detached EDWi HOME INFORMATION ; Make Model t Model Year �)��.:ap Length / _ 0. 0 edrooms _No. of Bathrooms ;2-- Type of Heat urchase Price $ " / ep ace o A er Name r .. Ce fication No. Gfl4 NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCI ION AUTHORIZED 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 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 ABOVE DESCRIBED PROPERTY AND STRUCTURES FOR REVIEW AND INSPECTION OF THIS PROJECT. OWNER/BUILDER ACKNOWLEDGES SU13MISSION OF INACCURATE INFORMATION MAY RESULT IN A STOP WORK ORDER OR PERMIT REVOCATION.ACKNOWLEDGEMENT OF SUCH IS BY SIGNATURE BELOW: OWNER AFFIDAVIT- I certify that I am exempt from the require- CONTRACTOR'S AFFIDAVIT - I certify that I am currently regis- ment of the Contractor Registration Law RCW 18.27 and am aware tered as a contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and of the ordinance requirements regulating the work for which this that all work will be done in conformance therewith. No changes permit is iSSL ed and all work shall be done in conformance there- shall be made without first obtaining approval. with. No chan es shall be made without first obtaining approval. X ".. Date - Q-Q X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by 1 (2.) Planning Pc Ck# 1 t Date 7 � _. ,2 Bld Pd. Reciept No. DEPARTMENTAL REVf` APPR VED DENIER CONDITION COD ES 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 R view Fee Mechanical&Base Fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid a ubmittal ( ) TOTAL FEES i E -1' wa r G 0 o K X ,o Li T nLD oT, f Z0 :Igdd 71IH QIAVC SSEbSBL09E> w oz E00Z/GZ/be _ 1! i r ' : — — —'----— - . —,— —T— I r ' ' t E Chat 47 I i � � I I i i i i 1 i I j I• 1 i � I I •j i i , � i i ttira�j�L'�4,rt D i b�!f! .I � I � , 04/29/2003 20:44 13607854355 DAVID HILL PAGE 01 J In '4C) S � t a r4 �g , T7 , r, ell I i 1 IF o CJNCAETE MECHANICAL MANUFACTURED HOME O 4 1' Footings / Setbacks Date By Ribbons 0 �C)„ Date / �,�0S By Gas Piping Date By w m Foundation Walls Date B y Set-up Date By INSULATION Date By B G / Slab Insulation Floors Final Date By Date By Date By FRAMING Walls FIRE DEPT Date 0 -25v 5 ___= B y ' Date By Date By PLUMBING Attic OTHER Groundwork Date By Date By WALLB07kRD�—B NAI D.W.V. Date/A — 4 y ........... Date By FINAL INSPECmy, Water Line Date 12 1 P 7435 Date By ,. . ro �� Date By ko IL. s � t I�3 +► �y o3 F- ,n ,4,I m a o )v- ,�v (- v m 0 8 oCD 0 d r o y w tsJ o W trJ �o �