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AldLr � b BUILDING PERMIT APPLICATION PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: 60 MAILING ADDRESS: 4111a U'll _ MAILING DRESS: CITY: dG jG'N STATE: LCI ZIP: Z-� CITY: STATE: ZIP: PHONE#l: "i fs- IW 21--91-141IS4111 PHONE:,;? . CELL: PHONE#2: R5/-- Z I`7 EMAIL : EMAIL: L&I REG EXP. PRIMARY CONTACT: t OWNER'X CONTRACTOR OTHER❑ EMAIL . 7/�-v�`rA/ CITY STATE MAILING ADDRESS a ZIP C_ PHONE Z2 4 - CELL V ` PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) - ZONING i� LEGAL DESCRIPTION(Abb reviated) FIRE DISTRICT SITE I(D ADDRESS LL '> .-),*X� A412-PCV i R 12 CI`1'Y DIRECTIONS TO SITE ADDRESS ` 0- !V T IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO X IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply): SALTWATER V LAKP,4 RIVER/CREEK PONDX WETLAN [ f SEASONAL RUNOFF [)( STREAM K TYPE OF WORK: NEW 0- ADDITION ❑ ALTERATION P REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) ` IS USE: �-P-TAIM 44-0 -SBA NUMBER OF BEDROOMS NUMBER OF BATHROOMS HEATED STRUCTURE? YES(Whole Bldg) ❑ YES (Part[s]of Bldg) ❑ NO X DESCRIBE WORK SQUARE FOOTAGE: (propose+existing) I ST FLOOR sq.ft. 2ND FLOOR --' �q•ft. 3RD FLOOR sq.ft. BASEMENT sq.ft. DECK sq.ft. COVERED DECK — sq.ft. STORAGE sq.ft. OTHER sq. ft. GARAGE ;-- - sq.ft. Attached❑ Detached CARPORT sq.ft. Attackeag-Detached 5� MANUFA �10 *4 COIES OF THE FLOOR PLAN REQUIRED* M E MODEL YEAR LENGTH IDTH BEDROOMS BATHS SE BER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC❑ SEWER NEW EXISTING❑ PLUMBING IN STRUCTURE? YES ❑ NO [.-I If ves, ttach completed Water.Adequacy Form PERIMETER&OUNDATION DRAINS PROPOSED? YES EXISTING SQ,FT. EXISTING BEDROOMS I A , PROPOSED BEDROOMS , TOTAL BEDROOMS OWNER acknowledges that 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 and I further declare that I am entitled to receive this permit and to do the work as proposed.I have obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal representative,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUAT ON OF WORK ON THIS PERMIT IS BY M ANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLJ, ATIO OF 180 DAYS OF MORE WILL CAUSE T IE APPLICATION TO BE EXPIRED. (MASON / COUNTY CODE 14.08. ) ignature of OW ER(Must be si ned by the OWNE.R Date - DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH