HomeMy WebLinkAboutBLD2012-00758 REROOF - BLD Permit / Conditions - 10/1/2012 §
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MASON COUNTY PERMIT NO -Id 0
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton(360) 427-9670• Belfair(360)275-4467•Elrna(360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner PAS', 6-- Company Name 4S al ' p � t� Z--
Mailing Address Mailing Addresses%l)_�
City .SiA-L—'t44 State_W Zip Code City State Zip Code
Phone Other Ph. Phone Other Ph.
Lien/Tide Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.4 DOB Drivers Lic•# DOB
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Water System Name of Water stem
PARCEL INFORMATION- 12 Digit Parcel No — Fire District
Legal Description
Site Address (Please include street name,street number and city)
Directions to site
Will timber be cut and sold in parcel preparation?Yes/No
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?Yes/No
TYPE OF JOB-New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL E]Use of Building Describe Work
No. of Bedrooms No.of Bathrooms Square Footage-1st Floor 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 Certification No.
OWNER/BU= Acknowledges submission of inaccurate information may result in a stop work order or permit revoceifori-Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contactor.i further declare that I am entitled to receive the
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 hoider,or any other party in interest regarding this application or the work proposed in the app6calion,I have obtained
parrrassion from them to apply mmit and conduct the work proposed The owner or agent on owners behalf,represents that the infomration
provided is accurate and g mpi f Mason County access to the above described property and structure for review and inspection.
PROOF OF C0K"nNU ORK IS MEANS OF A PROGRESS INSPECTION.
X Date-
Owner KNmars Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted b Date j )- (.- la
DEPARTMENTAL REVIEW APPROVED DENIED ! NOTES
Building Department ;
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building 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$ TOTAL FEES