HomeMy WebLinkAboutBLD2001-01316 Cancelled Replace Sheetrock, Electric Lights and Outlets - BLD Application - 12/26/2001 PERMIT NO.: BLD
MASON COUNTY
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 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner' /_=26) It, /1-I,*1TN/SUS Contractor Name 1 14?
Mailing Address'-63 Ajo & i 4hNuyw t?j Z>R. Mailing Address
City-Tt+ A%k% Af% State�A g Zip Code -TAyc-RA? City State Zip Code
Phone epo %-77-0s1u"3Other Ph.( Ph.( Other Ph.(
Lien/Title Holder�Pw tq s Contractor Reg. #
Address Expiration
SEPTICIWATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System Name of Sewer System Well Water System Name of
Water System 11 f)u c _,f�,7L IL
i
PARCEL INFORM/TION-12 digit Tax Parcel No. .2 .1 3 5z / 00,01 Fire District
Legal Description
Site Address(Please include street name, st number and city)Loa/ S1,4ke 4fP&4o:;1i
Directions to site-j ,w Lo C611 ,al" 61AST H
Id, Ao+-
Will timber be cut an Id in parcel reparati (Yes/No) x.
Is your property within 20 f the fol wing: od if Water(Name) Saltwater
Lake River/Creek Pond tl Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEAS L RESIDENC
TYPE OF JOB New Ad Alt Repair Oth Use of BuildingIZ—
Describe Work ' " > t
No. of Bedrooms No. of BatB\ase
SQUARE F O GE-1st Floor 2nd Floor
3rd Floor Loft ent Deck her V4 91cc,,& Shefitraeil sq. ft.
Garage Attached Detache ort a Detached ScG.•C-INC% cc.a
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 V rtification 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
approval. first obtaining approval.
X r Date t-e—2 6 '0/ X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date ubmittal Amount Due p Recei t No. r ��
DEPARTMENTAUREVIEW APPROVED DENIED CONDITION CODES
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
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