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•,r �� �A = MASON COUNTY Permit No: Ckmb5-036
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING•PLANNING•FIRE MARSHAL (360) 427-9670 Shelton ext. 352
http://www.co.mason.wa.us/community dev/ (360) 275-4467 Belfair ext. 352
�Rsa 426 W Cedar Street, Shelton WA 98584 (360) 482-5269 Elms t � VED
BUILDING PERMIT APPLICATION FEB 2 0 2015
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: 426 W, CEDAR ST,
NAME: Lilqdk NAME: -rM D C0% <-VA 314-
MAILING ADDRESS: E. Alta., S MAILING ADDRESS: (o ^ ri.spo oft A6 ' —4d#-
CITY: .5C%C41vr% STATE: W Or ZIP: I i9gy'( CITY: 5kJ4u% STATE: W* ZIP:
PHONE:, �y/S'- CELL: PHONE: t�?,(_-��CELL: 791 !20 t
EMAIL: EMAIL :
L&I REG# EXP.
CONTACT : OWNER ❑ CONTRACTORS BELOW ❑
NAME: gr&J MAILING ADDRESS: 6Q0 , ^10-aGft A„ IAA
CITY: STATE: L,../A- ZIP: f PHONE: 77 1 ,e 2 4 9 CELL:
EMAIL: —��
PARCEL INFORMATION:PARCEL NUMBER(12 DIGIT NUMBER) 4QD /A - 0 - D D 1 4� FIRE DISTRICT
LEGAL DESCRIPTION(ABBREVIATEED) :
SITE ADDRESS J (D50 45. CITY
DIRECTIONS TO SITE ADDRESS
IS PROPERTY WITHIN 200 FT:
SALTWATER- A` ❑ ILL POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
DOES PROPERTY HAV L HIN 300 FT F THE N 14% YES❑ NO ❑
TYPE OF JOB: NEW ❑ ADDITION ❑ ALTERATION❑ REPAIR'(/ OTHER ❑rr-- J
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) 9C I� C-C 4p,1AJ*%j i A dit�A�Dtlt Idea N N('� t Y
IS USE: PRIMARY ❑ SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHRMOMS
DESCRIBE WORK
SQUARE FOOTAGE:
1ST FLOOR sq. ft. 2ND FLOOR sq. ft. 3RD FLOOR sq. ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq. ft.
GARAGE sq.ft. ATTACHED ❑ DETACHED ❑ CARPORT sq.ft. ATTACHED ❑ DETACHED ❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
OWNER acknowledges that 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 or owner's legal representative. I further
declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the
necessary parties, including any easement holder or parties of interest regarding this project. The owner or legal
representative, represents that the information provided is accurate and grants employees of Mason County access to
the above described property and structure(s)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 OF INSPECTION. INACTIVITY OF THIS PERMIT
APPLICATIONOF 0 DAYS WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42)
X 0--`2 d- /-57
Signature of OWNER Date
DEPARTMENTAL REVIEW APPROVE DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRF_,MARSHAL
FEE'S QTAL VALUATION:
BUILDING PERMIT FEE FIRE ACCESS AND GRADE----
PLAN REVIEW GEO-TECH REVIEW
PLUMBING&BASE FEE STORMWATER REVIEW
MEC14ANICAL&BASE FEE TOTAL FEES
WOOD/GAS/PELLET STOVE VIOLATION INVESTIGATION FEE
PLANNING REVIEW FEE VIOLATION FEE
0 M
iZ CONCRETE MECHANICAL MANUFACTURED HOME
z
r1j
C) Date By --I
T Footings/Setbacks Gas Piping Ribbons 0
C) z
C) Interior Date By Interior-Date By Dale By
C)
W Extem Date By Exterior-Date
00 - INSULA11ON Set-up
Point Load I Isolated Footings Date By 0
Date By Data By BG I SLAB INSULATION >
FIRE DEPARTMENT
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 Atfic
Date By Date By Type,
Dale By
DRYWALL Type" 0
O.Wv Int Brace Wall Date 13y 0
Date 8 9
y D.t Sy INSPECTION
Water Line Fire Seperatloon 9
TDato By to By Date By
Q
C)
Pass or Request Inspect. CD
W
Type of Insp. Fail Date .—Date Deane Comments 00
(D
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0
1-2
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