HomeMy WebLinkAboutCOM2010-00068 Cancelled Fence - COM Application - 7/28/2010 MASON COUNTY PERMIT -
BUILDING PERMIT APPLICATION /-a
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
3D42-
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
I
Owner �ArS�-lh e SS L-,h j L-5_L_1"'S A5S0 c Company Name
Mailing Address—5-4 0 [, QAI- k P►-r Mailing Address
City S6-6 k"VI State W A- Zip Code 9 v-Sf-4- City State Zip Code
Phone 3C-6 42 1 -a 72 Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address E Mail Address
Drivers Lic. # DOB Drivers Lic.# DOB
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 P rcel No 2- Z— ao L-r�4-0 A Fire District
Legal Description L--ok4t'/ 1�
Site Address(Please in u e street name, street num er and cit hl '!�k
Directions to site b Nk�" 9 V c' -, 4-1 he S le, -:4 .
Szc' E��c1 irr- .4- S— l
Will timber be cut and sold in parcel preppa�ration? Ye N `
Is property within 200' of Saltwater�1�1�Lake N/� River/Creek 1��P nd �
Wetland _Seasonal Runoff �1 /_N Stream��Slopes or Bluffs ] 15% e
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 r IMARY RESIDENCE n SEASONAL ,n
Use of Building 5�c' `'ki z"Ta Describe Work—
No.
No. of Bedrooms � (lo� hrooms Square Footage- 1 st 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
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 om them to apply for this PQr-mi'tRnjJ coytWt the work proposed. The owner or agent on owners behalf,represents that the information
provid is ccu4andantemploy of asaap� un ss to the above described property and Structure for review andPROO C F O IS YME1A A PROGRESS INSPEC ON.X DateIOw ersentativ Contr c (indicate which one O
FOR O FICIAL USE Y2 D TH POINT Accepted by: Date
DEPARTMENTAL REVIEW PPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department twq
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
Violation Fee 1 1 Pre-Paid at Submittal
Valuation $ 1 TOTAL FEES