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MASON COUNTY PERMIT NO 1 G
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING® PLANNING® FIRE MARSHAL
_ WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason County Bldg. III,426 West Cedar Street , 0 (360)275-4467 Belfair ext.352
Ixs }` PO Box 279, Shelton,WA 98584 (360)482-5269 Elma ext.352
�, :�
BUILDINGPERMIT APPL14TION
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: JE�V 1 HA/ O NAME:
MAILING ADDRESS: MAILING ADDRESS:
CITY: gffel—EQ61 STATE: _ZIPq z_1 CITY: S E: ZIP:
PHONE:J( 7_C?(, CELL;y�jS/- i� LP PHONE: CELL:
EMAIL: EMAIL
L&I RE EXP.
PARCEL INFORMATION: `
PARCEL NUMBER(12 DIGIT NUMBER) FIRE DISTRICT___
LEGAL DESCRIPTION(ABRE ED)
SITE ADDRESS 0 CITY
DIRECTIONS TO SITE ADDRESS
IS PROPERTY WITHIN 200 FT:
SALTWATER❑ LAKE[IRIVER/CREEK❑ POND [I WETLAND SEASONAL RUNOFF❑ STREAM❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GRE TER THAN 14% YES[] NO ❑
TYPE OF JOB: NEW,]' ADDITION ❑l ALTERATION❑ REAIR e❑ OTHERF ❑
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) 11, Yam. ffl C��
eL
IS USE: PRIMARY ❑ SEASONAL ❑ NUMB R OF BEDROOMS NUMBER OF BATHROOMS
DESCRIBE WORK
S UARE FOO
is OOR !!�q.ft. 2ND FLOOR sq.ft. 3 sq. ft. BASEMENT sq.ft.
CK sq. ft. COVERED DECK sq.ft. STORAGE OTHER sq.ft.
GARAGE sq.ft. ATTACHED ❑ DETACHED ❑ CARPORT sq.ft. HED ❑
MANUFACTURED HOME INFORMATION: *4 COP OF THE FLOOR PLAN
MAKE (; VY1 `;Ji b e_, MODEL C� ��f' l �_ Y E.U1, 26 1 LENGTH .3
WIDTH I I BEDROOMS � BATHS I S NUMBER
OWNER/BUILDER acknowledges submission of inaccurate information may resul 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 contractor. I further
declare that I am entitled to receive this permit and to do the work as proposed. I ha obtained permission from all the necessary
parties, including any easement holder or parties of interest regarding this project.T i a owner or authorized agent represents that the
information provided is accurate and grants employees of Mason County access to a above described property and structure(s)for
review and inspection.This permitlapplication becomes null&void if work or author' ed construction is not commenced within 180
days or if construction work is suspended for a period of 180 days. PROOF OF CO INUATION OF WORK IS BY MEANS OF
INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL 1 VALIDATE THE APPLICATION.
X
Signature of Applicant Date
X OWNE REPRESENTATIVE./CONTRACTOR
Print Name (CIRCLE TO INDICATE)
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGSINOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
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