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FORM MUST BE COMPLETED IN INK PERMIT NO.: aD
PLEASE PRESS HARD MASON COUNTY
BUILDING PERMIT APPLIQATION
426 W.Cedar/P.O.Box 186,Shelton,WA 108584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5�69 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACT INFORMATION
Owner -^°'\ 90 , Contractor N e 4-
Mailing Address r..J / 1 1 e rwY!N c Mailing Addr S 762 U
City e ll\e14-0� State i--a-Zip Code City ce States^y Zip Code q,&®��7_
Phone( Other Ph.( ) Ph. 3Gc' -7 V they Ph.( 3.Gv
Lien/Title Holder Contractor R . # 13 e-V�.-, C :1 0_I 2-�
Address Expiration s'j -1A 107 / 2 0o Z
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic xisting Septic___y-_Connect to Sewer
System Name of Sewer System Well Water System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No. 9V A oC) / 7 / , I Fire District
Legal Description 3 „4 0 P v r y A 2 1/
Site Address(Please include street name, street number and city)
Directions to site- e 14 o
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water (Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt ,X Repair Other Use f Building
Describe Work - e /ice e,,< GOTP
No. of Bedrooms 1, No. of Bathrooms �71 SQUARE F OTAGE-1st I or 2 row 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport Attache I Detached
MOBILE HOME INFORMATION-Make Model Model Year
Length Width Serial No. No. of edrooms No. of Bathrooms
Type of Heat Purchase Price $ i Replacement Unit ?(Yes/No)
Installer Name Certification o.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHOR ZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. Th wner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the a 3ve 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' AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the Rate 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 reg i ating 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 nformance therewith. No changes shall be made without
approval. first obtaining ap oval.
X Date X 7 �- ''�"`— Date
FOR OFFICIAL
1 USE BEYOND TI1 IS P INT C�
Accepted by V Submittal Amount ue Receipt No._i=�/
EPARTMENTAL REVIEW APPROVED pENIED D C)NDIT1vN COPES
Building Department.-
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
i
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 Submi I ( )
TOTAL FEES