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Home My WebLink AboutBLD2007-01863 ReRoof - BLD Application - 10/25/2007 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO �V /^V 4 PLEASE PRESS HARD 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 APPLICA T INFORMATION CONTRACTOR INFORMATION Owner t6texA f 'c e, 10,0,rJu&t— Company Name 6"�' Mailin 1��ddfes 2/ at ✓ F/3 Mailing Address � / d&J' �;-d47 City g f State(Ve- Zip Code AJs'9-y City State 4/A Zip Code 99J',01 Phone Other Ph. Phone 1XII, SK- ,3,Q 2 Other Ph. 9 Y16 P Lien/Title Holder Contractor Reg. Z 1206,Z44/i/6e Exp. E 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 Well Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. 3,2 60 7 7 A ' v Z Fire District Legal Description 2 1z-C 42iZV 171-L31 !-6 C 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 ✓Qther PRIMAf3y R S DENCE SEASONAL ❑ Use of Building Describe Work �' No. of Bedrooms No.of Bathrooms Square Footage - 1 st Ffoor 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. GMNER/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 roposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed. X Dater Owner/Owners Representative/oContractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted Planning Pd Ck# Date l0?S-p'7 Bld Pd Receipt No. DEPA TM NTAL REVIEW APPROVED DENIED NOTES Building ep rtment 11pT f'lU EYl Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection 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 Valuation $ TOTAL FEES