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HomeMy WebLinkAboutCOM2015-00108 - COM Application - 7/23/2015 MASON COUNTY Permit No:L�m 2.6l -0010 v y DEPARTMENT OF COMMUNITY DEVELOPMENT ;.. BUILDING•PLANNING•FIRE MARSHAL (360)427-9670 Shelton ext. 352 http;//www.co.mason.wa.us/community dev/ (360).275-4467 Belfair ext. 352 426 W Cedar Street, Shelton WA 98584 (360) 482-5269 Elma ext. 352 BUILDING PERMIT APPLICATION PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: -I'r NAME: � � i MAIL AD RESS: h MAIL G ADDRESS: CITY. Uk k STATE: ZIP: CITY. STATE: W,4 _ZIP: PHONE:, CELL: PHONE: S .51 CELL: EMAIL:_ EMAIL : L&I REG# EXP. L CONTACT : OWNER [I CONTRACTOR [I BELOW ❑ NAME: I�Y�&4 0 , MAILING ADDRESS:'�o r -A4,5-4- �5 CITY: STA : ZIP: PHONE: CELL: EMAIL: o PARCEL INFORMATION: PARCEL NUMBER(12 DIGIT NUMBER) I a a? 3 Lq W rl© FIRE DISTRICT LEGAL DESCRIPTION(ABBREVIATED) SITE ADDRESS 2_�}1:1A hf: �+ _ CITY 1i DIRECTIONS TO SITE ADDRESS IS PROPERTY WITHIN 200 FT: SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND ❑, WETLAND ❑ SEASONAL RUNOFF ❑ STREAM❑ DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GREATER THAN 14% YES[] NO❑ TYPE OF JOB: NEW ❑ ADDITION ❑ ALTERATION❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) - IS USE: PRIMAR SEASONI ER OF BEDRS NLJMBFeR F BATHROOMS DESCRIBE WORK d I � SOUARE FOOTAGE: �M 0 L)K—T 1ST FLO sq.ft. 2ND s .ft. 3RD FLOOR sq.ft. BASE sq.ft. DEC sq.ft. COVERED DECK sq. R sq.ft. GA GE sq.ft. ATTACHED ❑ DETACHED ❑ CARPORT sq.ft. ATTACHED ❑ DETACHED❑ MANUFACTURED HOME INE RMATION: *4 COPIES OF THE FLOOR PLAN REOUIRED MAKE MODEL YEAR NGTH WIDTH EDROOMS BA SE OWNER acknowledges that 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 or owner's legal representative. I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or legal representative, represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s)for review and inspection. This permit/application becomes null &void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATIO OF 180 DAYS WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42) Signature of OWNER Date DEPARTMENTAL REVIEW APPROVE DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL r "y t�;`.,. }�,i.. 4 FE'I+k� ' � ' VAII AMOO1 {t, BUILDING PERMIT FEE FIRE ACCESS AND GRADE PLAN REVIEW GEO-TECH REVIEW PLUMBING&BASE FEE STORMWATER REVIEW MECHANICAL&BASE FEE TOTAL FEES WOOD/GAS/PELLET STOVE IOLATION INVESTIGATION FEE PLANNING REVIEW FEE VIOLATION FEE t, =s