HomeMy WebLinkAboutBLD2004-01873 STRG - BLD Permit / Conditions - 1/4/2005 C/) _
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CDCONCRETE MECHANICAL MANUFACTURED HOME
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Footings I Setbacks Date B y Ribbons
� Date f Jfi" Gas Piping Date By
V
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Date By INSULATION Date By
B G I Slab Insulation Floors Final
Date By Date By Date By
FRAMING Walls FIRE DEPT
Date By Date By Date By
PLUMBING Attic OTHER
Groundwork Date By
Date By WALLBOARD NAILING
D. .V. Date By
Date By FINA INSPEC
Water Line Date B y
Date B y D By
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MASON GUUN I Y 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.w' .us
APPLICANT INFORMA�N CONTRACTOR INFORMATION
Owner Company Na e ""
Ma Add r s Sd Mailing Addr s
City : ham State ,-Zip Code City State Zip Code
—
Phone ft Other Ph. Phone Other Ph.
Lien/TitIP Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic. DOB , f/ Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Fxis 'ng pt'c
Connect to Water System Name of Water System—
Well—Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description - '~ " '
Site Address (Please include street name, street numbe r and clt
9i ectiops to site d l'fM 7V 4*44 £'
Will timb r be cut and sold in parcel preparation?Yes/
Is property within 200'of Saltwater Xid Lake River/Creek— Pond
Wetland Seasonal Runoff/- Stream Slopes or BI fs 115%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New & Add_Alt Repair Other RI ARY R SIDEN ❑ SEASONAL ❑
Use of Building Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st F oor 2nd Floor
3rd Floor Basement Deck Covered Deck—Other Sq.ft.
Garaged Attached Detached X Carport Attached Detached
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 roperty and structure for review and inspection.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Z Date,
Own /Owners Re resentati Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: ." Date
DEPARTMENTAL REVIEW APP OVED DENIED NOTE ,`,
RECEIVED
Building Department
Planning Department DEC Q 9 2004
Environmental Health Department L !
T:
Public Works Department
Fire Marshal
FEES
Buildinq Permit Fee o if— Site inspection
Plan Review Fee us$- I at .`7c EH Review Fee
Plumbing & Base Fee Planninq Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Alpa Pre-Paid at Submittal
Valuation $ 7 1�. TOTAL FEES
,1 .
a BID!! 1 �
••• •