HomeMy WebLinkAboutCOM2005-00056 Cancelled Painted Sign - COM Application - 5/5/2005 FORM MUST BE COMPLETED IN INK MASON COUN I Y PERMIT NC
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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
APPLICANT INFORM TION CONTRACTOR INFORMATION
Owner kgj Company Name
Mailin Ad r ss - Mailing Address
City State JdL Zip Code City State Zip Code
Phon - 940 Other PW 3&0)i;L�_`5Q17 Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address d&I 1[ uldvJe ei,131e. cLY'Yl E Mail Address
Drivers Lic.# 4_ DOB - Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Fxisting Septic
Connect to Water System Name of Water System.
Well Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. 72 9330 'C F130 Fire District
Legal Description 1 -X S 20 1
Site Address (Please include street name, street number d city) 'r/ l
Directio to site /
Will tin46er be cut and sold in parcel preparation?Yes No
Is property within 200'of Saltwater Lake River/Creek AlL? Pond
Wetland�_Seasonal Runoffs&Stream Slopes or Bluffs > 15% N
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 , IDENCE ❑ SEASONAL
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Use of Building �C-J. �-O- Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor Prrd 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 �aIl rmission is
required from any easement holder or any other parry in interest regarding this application or the work proposed in the applic t o�(
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the info 92 n
provided is accurate nd rants employees of Mason County access to•the above described property and structure for revie my tionn.
PROOF OF CON OF WORK IS BY ME NS OF A PROGRESS INSPECTION. �+ lV/ c7 �Z
X Date: ���--C/J 8ELFAIR
Owner/Owners Representative/Contractor indicate which one OFF�t~E
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED ` NOTES
Building Department
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Ins ection
Plan Review Fee EH Review Fee
Plumbing & Base Fee PlanningReview Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
BUILDING RECEIVED
MAR 0 5 2005
QE(FAIR OFFICE CE
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