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Home My WebLink AboutBLD2012-00205 Dock - BLD Application - 4/10/2012 MASON COUNTY PERMIT NO.__9 BUILDING BUILDIeNG PoE RMITBox86APP�LI,wAA TION A11A n �-4 � Shelton (360) 427-9670• Belfair(360) 275-4467 • Elma (360) 482-5269 n+ 1 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner �}-��4� (�;�` Company Name SC �- Mailing Address Coy �� = c r�_ c Mailing Address P C ��Crs i D City State I�^'` Zip Code �'`�E�'� City '�c�`= State 1,02- Zip Code `� Phone "�� Other Ph I�vD 2 Q> -i.'-Ii q Phone 3(-G' d �_- `� Other Ph.30 -N`t)-�5 y - Lien/Title Holder �'S�FTlfll. f IS �,} _ Contractor Reg.# Jb ` f�_E�IEx . E mail address c - I `' `{ �^ E Mail Address -r t✓o"CL P10� Drivers Lic.# DOB `✓ Drivers Lic.#f,1 (-53o31'Y`�DOB1 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, Fire District Legal Description Site Address(Please include street name,street number and city) Directions to site n i Will timber be cut and sold in parcel preparation?Yes/Plea Is property within 200'of Saltwater Lake r - 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 ['SEASONAL ❑ Use of Building Describe Work No. of Bedrooms No.of Bathrooms Square Footage- 1st 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 r� Installer Name Certification No. �Cl OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of G 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 G permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.ff 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 Q permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information I provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection. PROOF O ATIONfOf W K I BY MEANS OF A PROGRESS INSPECTION. X J'/'/f, `?��' lYl�� - Date- ` �t� �� -2 Q Owner/Owners Representative/Contractor indicate which one �J FOR OFFICIAL USE BEYOND THIS POINT Accepted Date `4 lQ z X DEPARTMENTAL REVIEW APPROVED DENIED NOTES -- Building Department ftZ &4+( v� Planning Department - L - I Environmental Health Department n L, e_\j i L uLj Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing&Base Fee Planninq Review Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee +prI Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES Lfir"a;'`�t F f P - p \ .. � e 1. \ i ' r CA - a U V [ ^ 1 PLANNING � T� 'A L;,,SSET ACVS ARE MEASURED RECEATED FRO T4iE FURTHEST f f LPG; � C 2O1Z � FROJE T ILDING 1LhA5C'i� COISIV.T MASON COUNTY DCD PLANNING SITE PLAN REQUIRED TO BE ON SITE CHANGES SUBJET TO APPROV — y