HomeMy WebLinkAboutBLD N/A Cancelled - BLD Application - 4/2/1992 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
426 W.CEDAR/P.O. BOX 186 SHELTON,WASHINGTON 98584
427-9670 DATE ISSUED
PERMIT NO.
OWNER NAME MAIL ADDRESS CITY&Sj�WGVA,734
ZIP PHONE
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DIRECTIONS
TO JOB SITE
PARCEL i aQ l LEGAL
NUMBER CR. 1, 't W I.a,-A 11 A
CONTRACTOR NAME MAILADDRESS Cl I
&STATE ZIP
USE OF ,
e-,2 vy
BUILDING
CLASS OF NEW ADDITION TION R KM#f
WORK rREMOVE
DESCRIBE
WORK J v-
ammilk
AREA: NUMBE E q�; 4DITIONING.
ICE
ATE PERM S EQUIRE FOR PLUMBING, HEATING, VENTILATING OR AIR
RESIDENCE SgFt STORI S
BASEMENT SgFt BEDR -jj!RY R S.O ERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
DECKS SgFt BATHROO .SEA.& AL RES.OVU ENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER WORK IS COMMENCED.
CARPORT SgFt FIREPLACE IS CA RT/GARAGE
GARAGE SgFt CHED 0 DETACHED❑
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. c7 APPROVAL FROM THE BUILDING DEPARTMENT,
X OWNER DATE �'-Z S L 2-- X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT APPROVED DEPARTMENT APPROVED
YES No YES NO BUILDING VALUATION
HEALTH PUBLIC WORKS FEE
PLANNING FIRE MARSHAL BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
APPLjCATIONACCEPTEDBY
E� PLANS CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION
D.( BY CASH CK MO TOTAL
BUILDING PERMIT PLOT PLAN
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. Box 186 SHELTON, WASHINGTON 98584
427-9670
DATE ISSUED
PERMIT NO.
OWNER
NAME MAIL ADDRESSCITY&STATE ZIP PHONE
}-
S G �S N
DIRECTIONS me
TO JOB SITE -L. Aj
60 t.j- R
v
PARCEL LEGAL
NUMBER DESCR
Indicate below: O Property lines and dimensions.
O Easements and roads.
O Septic, drainfield and reserve area, or sewer.
O Septic tank and drainfield setback distances from foundations.
O Location of proposed construction on property.
O Building & septic system setback distances from all property lines easements.
Indicate North O Well and water line.
In Circle O Saltwater, lakes, rivers, streams,wetlands, drainage.
O Attach copy of septic system "as built' or septic permit approval.
O Indicate topography profile of property and structure on reverse side.
f �
Ilwe certify that the p oposed construction will conform to the dimensions and uses shown above and that no changes will be made without first obtaining approval.
SIGNAi URE OF C'WNER(S)OR AUTHORIZED REPRESENTATIVE
DO NnT WRfTF Qirr niv ruicc i ,.,--