HomeMy WebLinkAboutBLD2005-00129 Barn/Garage - BLD Application - 1/28/2005 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.�. QOO�;i- OCR
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 �v
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 :!-0-1 RYt R-L r Company Name
Mailing Address P. 0. 30X 39/ Mailing Address
City 19c?-FA P —State_W t Zip Code 225-2-R City State Zip Code
Phone�6,r--3-72,-21,11 Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.# Or'0Z L SH 3:C1 KLI-) DOB 5--1 E -7b Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Fxisting Septic X
Connect to Water System Name of Water System
Well—Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. 757-0 Fire District Z
Legal Description -
ws
Site Address (Please include street na , street number and city) 00 t 1
Directions to site 1 - L w��' Ise 146+nyA - S11y Ic Swi 1T)1 AD. % 1I_c d��✓N
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Will timber be cut and sold in parcel preparation?Yes o �R IqZ �cN�
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
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 E Describe Work
No.of Bedrooms No.of Bathrooms Square Footage- 1 st Floor j LEI 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 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 County access to the above described property and structure for review and inspection.
PROOF OF CONTINUA ON OF ORK IS BY MEANS OF A PROGRESS INSPECTION.
X - Date:
�
&er/ownerqrge rXsentative/Contractor indicate which one
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 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 Pre-Paid at Submittal
Valuation $ TOTAL FEES