HomeMy WebLinkAboutMobile Home - BLD Application - 3/9/1987 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
426-5593 DATE ISSUED
PERMIT NO.
NAME MAILADDRESS ZIP PHONE
OWNER P2� Z`
DIRECTIONS
TO JOB SIT
ACf_
c < -
PARCEL LEGAL
NUMBER L/) DESCR. -rP,— CIF tu Lo 1�
NAME MAILADDRESS CITY&STATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF
BUILDING �� \
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK ✓ 7
DESCRIBE
WORK
BEDROOMS DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS c4, TOTAL SQ.FT. GARAGE CONDITIONING.
NO.OF STORI ES BASEMENT ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SQ.FT. FIREPLACE DETACHED ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PERMANENT SHORELINE
SEASONAL
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGISTRATION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIREMENTS FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WORK DONE WILL BE WORK FOR WHICH THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
IN CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINING APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
"7
X OWNER/ ,5 11L ATE X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT YEAPPROVEDJO DEPARTMENT YES DEPARTMENTBUILDING VALUATION
HEALTH PUBLIC WORKS FEE
PLANNING V1 FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDINGGROUP PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATE SURCHARGE
APPLICATION ACCEPTED BY PLANS C ECK BY APPROVED FOR UANCE PERMIT VALIDATION r'
�z/iI�" BY CASH CK MO TOTAL 7�
g aLSSOR
T t.J E "" A S n ^: C 0 T Y S n A , c
Pn:lrLAS JOITS
lt"IEF n r n,JTY
PLEASE SUPPLY T9E rnLUII.'' r; rlrnTII TIne,°
nar
REr,ARrl�,'n Vol!" -n,- lLf
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�< Tele #
Owners name; �'
Mailing Address
Previous "lobile Hone Owners Name & Address
Description of Mobile Hor.e: (Information is on your reristration certificate)
?sake V - Size C .
y
Year— Serial # ��
Year Purchased-2?rice (Less furniture & sales tax) -
If locating in Mobile Home Park:
Naate of Park: Space
If !OT in 119obile Hone Park:
P�
Do you own the land on which the home is placed.? Yes . o
Real Property description
Owner of Land if you are 40T the Owner:
Brief direction to location:
A 14401 2�
Date PIobile Home .Entered Mason Countv:
Date you anticipate moving Mobile Hone to another location:
If moved fror. a Mobile None Park rive:
Space #
�!ame of Park:
Your hone will be placed on the rolls of fl'ason County. '!e would appreciate a
nrompt reply. Please feel free to contact this office if you have any ouestions
at all .
Very truly yours,
Helen Claser
Personal Property Department':
L24Wn pnature �---flat
PLOT PLAN
ADDRESS PERMIT NO. o 0
= o
n >
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LEGAL
DESCRIPTION LOT BLK ADDITION
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS Sq. Ft.
INSTRUCTIONS TO APPLICANT
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN 1"-20' ARE
FILED WITH PERMIT APPLICATION. (EACH BUILDING SITE MUST HAVE A SEPARATE PLOT PLAN.)
FOR NEW BUILDINGS PROVIDE THE FOLLOWING INFORMATION IN THE SPACE BELOW: LOCATION OF
PROPOSED CONSTRUCTION AND EXISTING IMPROVEMENTS.SHOW BUILDING,SITE,AND SETBACK DIMEN-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION AND SEWER SERVICE ELEVATION. SHOW LOCATION OF WATER, SEWER, GAS AND ELECTRICAL
SERVICE LINES.SHOW LOCATION OF SURVEY PINS.SPECIFY THE USE OF EACH BUILDING AND MAJOR POR-
TION THEREOF.
0 INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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�I
I/We certify that the proposed construction will conform to the dimensions and uses shown above and that no changes will be made without
II� first obtaining approval.
NAME($) OF OWNER(S) OF SITE 6 STRUCTURE(S) (PRINT) SIGNATURE OF OWNE ) OR AUTHORIZE -REP ESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE