HomeMy WebLinkAboutCOM2006-00028 Replace Sign - COM Application - 3/9/2006 MASON COUNTY PERMIT NO.UM dd1Q(y-
BUILDING PERMIT APPLICATION U 0� '
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
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner j 0,,�t� sP7 Ats t .,,r + S`S c.� t> v Company Name
Mailing Address t :ja N-v_:7 1 woY ya65 i Mailing Address
City +� F�� State%JO/>- Zip Code S2497—$ City State Zip Code
Phone?'z q 2U Other Ph. 'Z:Z V 9C 1 Phone Other Ph.
Lien/Title Contractor Reg. # Exp.
Email address E Mail Address
Drivers Lic.#+f tea DOB - Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System--
PARCEL INFORMATION - 12 Digit Parcel No. F're Jai t
Legal Description -}
Site Address (Please include street name, street number and city) P4 - t k 7+ 6 A
Directions to site o •_i L" -+� +�' "� • >Y
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
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 9A 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.
OWNER/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 permission from all
the necessary parties. If 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 permission from them to apply for this permit and conduct the work proposed. The owner or
agent on owners behalf, represents that the information provided is accurate and grants employees of Mason Co
described property and structure for review and inspection. This permit/application becomes null & void if work r
not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANSOFA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE 4FT9C N.
x */��- %A F-- , __......,..,,,,,,...._ Date: ;3 — —N6 M(�-1VIASON COUNTY
Owner/Owners Representa 7"Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW ARPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Departure
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
Violation Fee Pre-Paid at Submittal a�
Valuation $' 00 X; TOTAL FEES
f � 1
Ao :+DVED
I+� MAS'ON COUNTY DCD PLANNIN
SITE P REQU tj TO BE ON SITE Cl IA JECT TO APPR VAL
By _ Date �br
s
r
tRECEIVEJ3
MAR 0 9 2006'
l ' :° MASON COUNTY