HomeMy WebLinkAboutBLD2002-00712 Garage - BLD Application - 5/28/2002 FORM MUST BE COMPLETED IN INK PERMIT NO: BLDOr--
PLEASE PRESS HARD 410N COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
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Shelton(360)427-9670 Belfair(360)275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR. INFORMATION
Owner RobmE,4 � Dom ►TA Pol sot4 Contractor Name v.✓
Mailing Address 4'16.2s- S WSJ tA Pc.. ' Mailing Address
City. A a,b,a rv\ State� Zip Code 9KO01 City ate Zip Code
Phone( s3 ) 9y/-6 Z.7SOther Ph.( ) Ph.( Other Ph.(
Lien/Title Holder :5p me_ Contractor Reg.
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic _Existing Septic Connect to Sewer
System Name of Sewer System Well_X Water System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No. 2 Z 3 3 Q I 5-0 / OG I Fire District
Legal Description Htquenl LAI<F_ 7i2
Site Address(Please include street name, street number and city)
Directions to site "rAkt- /lortt, Slice J wesf o4 ;,- Tar,, d ,r- .A. , R r �LL�
N gAvexi L k On a .s+, r r; 4 +n C., /�
Will timber be cut and sold in par el preparatio ? (Yes/No)J r,5kt s, - Ler/ q
Is your property within 200' of the following: Body of Water (Name) 14Aypn.1 L rake- Saltwater
Lake_ River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE I]
TYPE OF JOB New K Add Alt Repair Other Use of Building rec-r-* 10,1
Describe Work a
No. of Bedrooms7-No. of Bathrooms QUARE FOOTAGE- _ 2nd Floor
3rd Floor Loft Bai� Bec Other sq. ft.
Garage <//(o Attached Detached _Carport Attached Detached
MOBILE HOME INFORMATION-Make Model 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.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
appTo first obtaining approval.
X Rol Date J�,Z.B O Z- X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPgQVEDe DENIED CONDITION CODES .DZ
Building Department NP
Occ Group - Type Constr.V r casfS 11M' - 001
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
Valuation $
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 ( )
TOTAL FEES