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Fail Date Date Done By Comments CD (D ........................ (D MASON COUNTY PERMIT NO.1�1 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 APPLICAt4T INFORMATION CONTRACTOR INFORM TION Owner ( r C h Company Name Mailing Address CCU r Mailing Address - n tl City -S Le r&jZ—State Zip Code SrP,.S f��� City .Sh,e llo6- State t,��t—Zip Code Phone Other Ph. Phone 6/2°7 3267 Other Ph. Lien/Title Holder Contractor Reg. # Exp. E mail address E Mail Address Drivers Lic.# DOB I 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 /4 7 Fire District Legal Description Site Address (Please include street name, treet number and city) Direction to sit �/D6/tti< < a' T_ ��2 — < <fN r✓l c lit will timber 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 EASONAL ❑ Use of Building Describe Work No. of Bedrooms No. of Bathrooms Square Footage-\14t 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. PROOF OF CONTINUATIONQF WORK IS BY MEANS OF A PROGRESS INSPECTION. X � 9 Date t �� Owner/O epresentati /Contractor ' dicate which one) FOR OFFICIAL USE BEYON OINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department. - Public Works Department Fire Marshal FEES Buildinq Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview Fee Mechanical & Base fee Other Wood/Gas/ Pellet Stove Fee I State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES