HomeMy WebLinkAboutBLD2001-01051 SFR - BLD Application - 10/5/2001 aobwlos1
FORM MUST BE COMPLETED IN INK PERMIT NO.: BLD
PLEASE PRESS HARD MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275�d467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name �:f.2/V`
Mailing Address WSG wA, Mailing Address
City Uvivoo _ State IA2g Zip Code > City State Zip Code
Phone(360 ) R'4R-571MOther Ph.( ) Ph.( Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic connect to Sewer
System Name of Sewer System Well ) Water System Name of
Water System
PARCEL INFORMATION-12 di it Tax Parcel No. 3 z / / ti Fire District
Legal Description ro 3 T 3 0 — T A .
Site Address(Please include street name, street number and city) 0 O t w 0
Directions to site 0 !x .� �r
A-KK
ill timber be cut and sold in parcel preparation? (Yes/No) kko /�1�
Is your property within 200' of the following: Body of Water(Name) L)V.ot u4,4 t- Saltwater K
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE$] SEASONAL RESIDENCE❑
TYPE OF JOB New 3�Add Alt Repair Other Use of Building zs,�e,J�igL
Describe Work ,it, ! Nec,) f ILoMe--
No. of Bedrooms 2_No. of Bathrooms 'L {-SQUARE FOOTAGE-1st Floor 7-5 2nd Floor
3rd Floor Loft Basement Deck /7( Other sq. ft.
Garage LJJ AttacheoC 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 P Replacement Unit ?(Yes/No)ri $
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-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contra 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
requir me is for which this per is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conf rma ce therewith. No n es shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
app val. first obtaining approval.
f
X4" Date X Date
--� FOR OFFICI USE BEYOND THIS POI(N�T, `���
Accepted by ��S4-I Dubrnittal Amount Due�O —I f Receipt lu
D.EPARTMENTAL<REVIEW APPROVED DENIED CONDITION CODES
.. .............
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
Valuation $
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 ( )
TOTAL FEES