HomeMy WebLinkAboutCOM2001-00114 Storage - COM Application - 7/20/2001 f{
FORM MUST BE COMPLETED IN INK '�F-i� ~ !r
PLEASE PRESS HARD PERMIT NO.: BLD�
MASON COUNTY
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 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner ; r-P Ger-bf,%c Contractor Name 10/N<-,
Mailing Address E 7 4:0 g4-6y �'cf Mailing Address
City (/iv11J1U State W f Zip Code qe,."?2 City State Zip Code
Phone 3c.a ?`1 P zy,A,.6Other Ph. Ph.C�_ Other Ph.(
Lien/Title Holder Contractor Reg. :F
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
tLegal
Name of Sewer System Well Water System Name of
System
EL INFORMATION-12 digit Tax Parcel No. _3d,a3.2 / 3 / UODi 0 Fire District
Description TR t of `' ` V
ddress(Please include street name, street number and city) C: 7 5 /91-ons to site
Will timber be cut and sold in parcel preparation? (Yes/No) AIQ
Is your property within 200' of the following: Body of Water (Name) Saltwater
Lake River/Creek `i. Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE SEASONAL RESIDENCE❑
TYPE OF JOB New Add Alt Repair Other Use of Building ifu= o' iy) r„��.
Describe Work I' J:e I
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st Floor.241 1D 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model 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.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
Ix Date ` �f �/ X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL.I.REV1EW APPROVED DENIED C0NDITI0N CQDES
Building Department
Occ Group Type Constr.
Planning Department ! ��
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES T
Building Permit Fee Site Inspection T Oo
Plan Review Fee EH Review Fee
Plumbing &Base Fee Planning Review Fee
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES