HomeMy WebLinkAboutCOM2001-00002 Addition Dining Hall - COM Application - 1/5/2001 PERMIT NO.: BLD
MASON COUNTY �.
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 Seattle (206)464-6968
APPLICANT INFO RMA 'CONTRACTOR INFORMATION
Own Contractor Name
Mailing2- r,-TJ-C� I-el W Mailing Address
City TJ m ivc,+e r- State tk1r Zip Code / ity State Zip Code
Phone 3( �o (y9G Other Ph.( 3 6 r)�e Ph.( ) Other Ph.(
Lien/Title Holder sf /�„S T�t-'Sf Ag-ree�/++ Contractor Reg. #
Address n Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing eptic1/Connect to Sewer
System Name of Sewer System �' ' 11�/ell Water System Name of
Water System f,
PARCEL INFORMATION-12 digit Tax Parcel No. 112- /6— Fire District
Legal Description "Kec.�aod n IoAt-�+�l e►s nF SR -3 LOT 3(► lhCU R KM W s
Site Address(Please include street name, street number and city) A.5 1 A=, I-CC'4 F-- D,C--'VV eetALI X &,o
Directions to site SAD LKVCVeremA�j
// �3 I
Will timber (Ye e cut and sold in parcel preparation es/ro�v
Is your property within 200' of the following: Body of Wa r (Name) ran Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add `✓ Alt Repair_ Other Use of Building
Describe Work c i c
No. of Bedroom No. of Bathrooms_SQUARE FOOTAGE-1st 1FIoor_ffJ420-J�2rfd Floor
3rd Floor Loft Basement Deck Other7ze-nuz4h nzipf. sq.`ft. AW
Garage Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model 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.
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 the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance 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 will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
appro I. r first obtaining approval.
1
X Date �� X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Dat4%S--0 Submittal Amount Due 3d�-� Receipt No. �J
DEPARTM NTALR)EVij5W APPROVED QI51Vieb CONDITION CODES
Building Department
Occ Group - Type Constr.X I-jij
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
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 ( ) s
TOTAL FEES