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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date by
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date FRAMING by date by date by
Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING i
date by date by
Water Line FINAL INSPECTION
date by dateLO-6_ �® by date by f
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PERMIT NO.: MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton(360)427-9670 Belfair(360)275-4467 Elma(360)482-5269 Seattle 206)464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owned A rry 1\ae-?rk Contractor Name
Mailinq Address Mailing Address
City SfatdD,.,& Zip Code City State-- Zip Code
Phorib(,2- [ ) -Vl,70ther Ph.( ) Ph.( Other Ph.(
Lien/Title Holder f\&,A qJ MAM. contractor. #
Address LExpiration PARCEL INFORMATION-12 digit Tax Parcel No. I)Iklj 44/) Fire District
`7
Legal Description
Site Address(include street name grld city le / _Directions to site:
Will timber be cut and sold in parcel preparation? (Yes/No)_
ru.".�
Is your property within 200' of the following: Body of Water(Name)
4_ 1 Saltwater
Lake River/Creek Pond Wetland Seasonal Rurloff Stream Slopes or
Bluffs
TYPE OF JOB New Add-Alt Repair_j/_Other Use of Building
Describe proposed construction Me pc 0 E'P
SHORELINE PROJECTS New Replacement4 Repair Expansion_
Bulkhead Material (concrete, rock, wood, etc.) Length Height
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEP INDING ON THE TYPE OF PERMIT.
I
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION 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. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
will be done in conformances I
�erew h. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first obtaining approval. be made without first obtaining approval.
*�4 Y 9c" X
Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by r Datej)/�/ Submittal Amount Due Receipt No.
4
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department
Occ Grp Type of Con t.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee Other
UFC Plan Review Fee Other
Violation Fee Pre-Paid at Submittal
TOTAL FEES