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(D 00 CD lD 0 C w CD 7 (n (D w C) (D Cr D O 3 (n N N (p •p 3 O Q. p �• Q- A N � C � W 03 .3-F O. 0 (Q 7 3 0 y tn. a CO Y (n CD 0 v CD 0 Q C7 , p 0 3 (D 3 CD 6 D O 3 (� s m in- (n c o 0 0 �_ o CD W >T 3 5--a CL � O � 0 .rNJ O woo O O — w 0 (/�D .I7 (Oj 0 3 O O " 3 0 (n m cn l F 3 t.7 w O j -s iZ N N c (Q (n - w N Q. CD. � w 3 03 CD O CD o' CD w (0 (D ((nn °' n cfl p a 0OL O cr 3 -0 m o 0 — n X o �• M. j w 0 CD (D CL _CD . p ° CD 3 0 0' 0 p =r D Q n O Q 3 _ (nw N Q _. Q 3 < <D w 0 N 0 v (D v ._� w lD (a O (D A w � C N (D "" v (D N < N CD CDco cD F 0 3 CD 03 r MASON COUNTY PERMIT NO 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.wa.us APPLICANT INFORMATION CONTRACTOR FORMATION OwnerGRA�iE)`-rE t-AIJL-mr--N w k"— Company Name 5j r"— i� A �- �Ac E® Mailin Address Mailing Address �— City S�E-'ra State Zip Code ' City CLXICO StatA Zip Code �W Phone '24C Other Ph. Phone �- a Other h. Lien/Title Holder Contractor Reg.,# _ i�iai�- p 3 E mail address E Mail Add ressle%�1 iNIS 1>0 4 % 4.'61` L-1' h0tW1 Drivers Lic.# DOB Drivers Lic.# W^VST W dtSZfici DOB 10--Zq'0O SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No z.e;+Z- 2- C00C ir: Fire District Legal Description t�Ai+ i� oT ° � _ Site Address(Please inc!&Lde street name,street number and city) Directions to site 0 Y" -�-� � P-0 PkD _ 'j p''w" E 0044 L--AS crij C.el Zvi 1-j a 10 ttT Will timber be cut and sold in parcel preparation?Yes No' Is property within 200'of Saltwater, t,O Lake River/Creek Pond �' a Wetland Seasonal Runoff-I" Strew Slopes or Bluffs > 151/6 V v Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes o TYPE OF JOB -New Add Alt Repair O j 4, , TONAL [� Use of Building Describe Work �' 1�� No. of Bedrooms_ No.of Bathrooms_Square Jt�}. ,t � � a 3rd Floor Basement Deck Coverea vecK umer aq.n. Garage -> Attached Detached Carport Attached Detached t 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/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.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 permission from all the necessary parties.If permission is required from any easement holder,or any other party in interest regarding this application or the 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 QF CONTINUATION QF WORK IS BY MEANS OF A PROGRESS INSPECTION. X C{ �—f Date: I o-- -7 i Owner/O ers Representativ Contractor (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 Buildinq 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 00 o CONCRETE MECHANICAL MANUFACTURED HOME w C No Date Footings BSotbactcs Gas Piping itlt&aona T` O Intenof Date By interior"Date By Date By Z 00 Cn F_xtefkw Data B r11 y Exterior-Rake By set-up � INSULATlC1N Point Load i Isolated Footings Dates By n BG I SLAB INSULATION --�°.� Z Date By Data By FIRE DEPARTMENT y Foundation Wails Floors Date By ;0 r- Date By Data By DECKS 0 FRAMING Walls Date By m Date By Data By PROPANE TANKS PLUMBING vault Dat� BY Data BY _ OTHER Groundwork Attic Rake E3y Type„ Date B y Date By D.W.V DRYWALL Type: Int,Brace Wall Rate B y 03 Date BY Date FINAL INSPECTION 0 v m N Water Lino Fire Seperatian o Date By Date By Date By Pass or Request Inspect. c Type of Insp. Fail Date Date Done By Comments 00 . . iI AzovI oy .Iron IN O 0 O Q O 7 N O 3 � (E (D 3 N (D 0