HomeMy WebLinkAboutBLD2014-00076 - BLD Application - 6/4/2014 vt c
,few MASON COUNTY PERMIT N0. 2-01�1-
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING• PLANNING•FIRE MARSHAL
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
_ Mason County Bldg III. 426 West Cedar Street (360)275-4467 Belfair ext. 352
PO Box 279 Shelton, WA 98584 (360)482-5269 Elma ext. 352
BUILDING PERMIT APPLICATION
OWNER INFORMATION: CONTRACTOR
R INFORMATION:
NAME:NAME: Nt ui U 0-hau NAME: fIful 1�71��1 Ul�l/i0y1
MAILING ADDRESS: MAILING ADDRE S: S
CITY: 02I u.�' STATE: p/A_ZIP: CITY: STATE:IL1��ZIP: 3,
PHONE: CELL:P���5�0- 855� PHONE- (z 7d CELL:
EMAIL: EMAIL :
L&I RE G# EXP. /2-/,3i//57
PARCEL INFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) FIRE DISTRICT
LEGAL DESCRIPTION(ABBREVIATED):
SITE ADDRESS R3 0a A(E S464FeP 3 CITY
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 P,-- ,ee/'V0F10
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.)
IS USE: PRIMARY ❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
DESCRIBE WORK
79 O
SQUARE FOOTAGE:
IST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft.STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. ATTACHED❑ DETACHED ❑ CARPORT sq.ft. ATTACHED❑ DETACHED ❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
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 contractor. 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 authorized agent 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 permittapplication 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 CONTI U TION OF WORK IS BY MEANS OF
IN�IPECT N. AC,T TY P MIT APPLICATION OF 180 DAYS WILL I DATE THE APPLICATION.
\\ Signa e f can Dat
x �; 6 Ji OWNE /REPRESENTATI ONTRACTOR
Print Name CIRCLE TO INDICAT
DEPARTMENTAL REVIEW APPROVED DATE, DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL