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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 APPLIC NT INFORMA ON CONTRACTOR INFOR TIOrN O ine,r a�@�.J— _ Company Name CYz"� �tG�oc' r-'C, Majhng Aoaress t ac-�� _I Mailing A,cddress r$� CityOJ���o� State 1�04 Zip Code `6 City State State Zip Code Phone�1Oo- 4a�1- 911-1 Other Ph. Phone - O6- a -`b1O I Other Ph. Lien/Title Holder Contractor Reg. a $ Exp. 1010--- F mail address E Mail Address Drivers Lic ---------- - ---- DOB.--- Drivers Lic. DOB— SEPTIC / WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic _ Connect to Water System Name of Water System Neil Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No - - o Fire District Legal Description Site Address (Please include street name, street number and city) I ho ace - S Directions to site Will umber be cut and sold in parcel preparation? Ye /No Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Is this permit submittal the result of a Stop Work Notice, Correction Notice or other enforcement action? Ye No TYPE OF JOB - New__-- Add-__- Alt_—_ Repair_ _- Other_____.__ _ PRIMARY RESIDENCE © SEASONAL ❑ Use of Buwla,ng Describe Work No of Bedrooms No. of Bathrooms Square Footage - 1st Floor 2ndFloor 3rd Floor_ Basement Deck Covered Deck Other Sq. ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Lengtn__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 entmeo to receive finis permit ane 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 regwred lron-,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. PR F OF CONTINUAT ON OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X nay Date y-4- a-01'- Owner/Owners Re resentative Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted oy ( • _ - Date h _jy�__ DEPARTMENTAL REVIEW VEDI DENIED NOTES ,g Derartment Planning Department Environmental Health Department V^ orhs Department -ire t:"arsr,ai - FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee P!unbinq & Base Fee Planninq Review Fee ^echan cal & Base fee Other ooc . Gas, Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation S TOTAL FEES `'0�1 g21967p Gal alr (�60� ?�5.aa67 NON- S TRUTURR r RE Ro U !�o! Slope 5(a I � S&, a UodcrlayrOt nu ' o�. F"�Qzg InsuJaoon- e(+- New (r�suJauon ^• s o;>< C SCC00p Roo f :lo R90g. I pc anl.s t b< io di root Cos`n0g CRCscc000 R9oS - - o 101)1.S czccp000 1a & 1b E cs�`�$ r�js s b.z1J be ias u1a 4cd to �c z z Tb c rpo( u o uni n " o AU d oriasu!l uoour vd o o 'o �z �o V cdC(ood;L c-c'C b 0 0 0 � `s�C JCCCO806 `'= rl�c 50 Of �b �0 f k r a rt i t h�I J be r u p p Lrd vucjos b vo LL u rP.acc �o be YC4(c!, ''�co4l,�oc r_c PP<r Porci°o of c6< rpuc ro be cauLcd, Lb nd oo�mon LL r o t/ 00 r- > 0 CONCRETE MECHANICAL MANUFACTURED HOME z N) (D Date By Footings/Setbacks Ribbons X Gas Piping m C) Intedo(Date By Interior-Date By Date By C) Exterior Date By Exterior-Date Bv Set-up CD INSULATION X Point Load I Isolated Footings Date By 0 BG I SLAB INSULATION 00 Date By Data By FIRE DEPARTMENT m X Foundation Walls Floors Date By Date By Data By DECKS FRAMING Walls Date By Date BY Data By PROPANE TANKS PLUMBING Vault Date By Date By OTHER Groundwork Attic Date By Date By Type, Data By D.W.V DRYWALL Type, Int.Brace Wall Date By Date By Date By (D - FINAL INSPECTION 0 W U) Water Line Fire Separation IS3 CD CD Date By Date By Date "'�/J 7 BXXI'L. C Pass Or Request Inspect. CD-DA 71 -- Q 0 5 Type of Insp. Fail Date Date Done BY Comments (D Q ti 0. A4;L (D O 0 .............................. ..........................S CA 0 CD ——-___------ Sv (D 0