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Int Brace Wall Date By Date By Date By 17- FINAL INSPECTION 0 (D Water Line Fire Separation N) CD Date 13Y Date B y By CD Pass or Request Inspect. Cu) 0 Type of Insp. Fail Date Date Done By Comments co (D CD cc cc (D 0 Not< :3 (n O fitl, V-71 eWC7Ft (D 15."S OC-11 iA ................. 4 0 MASON COUNTY 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.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner Company Name Mailing Address Mailing Address City State Zip Code City State Zip Code Phone Other Ph. Phone Other Ph. Lien/Title Holder Contractor Reg. # Exp. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.#a DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic . Existing Septic Connect to Water System Name of Water System Well Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. Fire District Legal Description Site Address (Please include street name, street number and city) Directions to site Will timber be cut and sold in parcel preparation?Yes/No Is property within 200' of Saltwater Lake River/ Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs5; 15% 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 PRIMARY RESIDENCE ❑ SEASONAL ❑ Use of Building -------Describe Work No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. Garage Attached Detached 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 property and structure 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 CONTINUATION OF WORK IS BY MEANS OFA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW AIPP.ROVIEP DENIED NOTES Building Department e` Planning Department Environmental Health Department Fire Marshal FEES Building Permit Fee 7 Site Inspection Plan Review Fee 2-7 EH Review Fee Plumbing & Base Fee T Planninq Review Fee Mechanical & Base fee Other Wood /Gas/ Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Z Valuation $ TOTAL FEES move • : • • . .. • MEASURED---ALL SETBACKS ARE Film ■■■■■■■■■■■��� ■■■■■■ ?�■■M■ ■■■i i■�■■� - ::■■■ ��■■■■■■■■■■ ■■■■ ■■■■■�► �i 'v■■■®■■■1■ OEM ■.■■■ ■■■ ___ ■ ■■■�■■�■■■ ■■■i ■■■■ 'i�■ 1■■��mo■0 NONE Hill ON 0 ■■■�■■■■■■■ ME ME ou mi ■■�, il.�■■HE I IN MIN 01111--now- MOM ■■■t�■■■■■■■!1 �I�/.�■■■� ■■■1l1 ■I ■MEE 10 / fit■ !■■■■■■■I■ ■a ■■■■■�■// ■■I■■■1�■®■■■■■I■ ■■Is■■■■■SA M 0�■■■■■■■1■■■�i■■■■■■■�■ ■l! ■■■ ■■■■■■■■�■ Mfg ■■■■■■■■■■ ■� ■ m■■■■■■■ ■■ !�■ ■■■■I■ 0 ®fir/■■■■■■■■■■■■■■MIN ■■�■