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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 S a Company Name Mailing Addresq Mailing Address City flvril State Lk,_Zip Code City State Zip Code Phone Other Ph. ' ?--994/0 Phone Other Ph. Lien/Title Holder tW� ` Contractor Reg.# Exp. E mail address E Mail Address Drivers Lic.# 5myrYTw3ho'DOB f Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. 4i L- 012— 2 _ Fire District Legal Description A,a/ 6 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 Bluffs > 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 - 1 st 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 permis- sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica- tion or the work proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed. X Zt( Date: Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bid Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Departments-I 4—/G, 2 pri Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Ins ection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES PLANNING o P6 ►c� APPOVED MAS N COUNTY DCD_PLANNING 6 SIT PLAN REQUIRED TO BE ON SITE 3 C NGES SUBJECT TO APPROVAL Date v4, 34G L 232 2Y3,. C7AR�°QF- c� M Pow F MPuce. 38 29,` tfOuS 26!` 1 z44 Sa FL PROosm), k Stp U)'q `�R. < P RE o Po ScAtE i 5o, =. 6 0 4ZolZ Ln 22 , TAD 5M.I;rH (�y0: Ost gPAWGI ,pd' j EAsT SPRlA R® �