HomeMy WebLinkAboutBLD12314 Bulkhead - BLD Application - 4/21/1982 J . BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 ?'a1�
DATE ISSUED
PERMIT NO.
NJ;E MAIL ADDRESS CITY 8 STATE ZIP PHONE
C4' "4ov 2 fiS .s i�.4 35�6o Nw o eI&Ioe 9�Sz8 .27s s"s�OWNER
DIRECTIONS
TO JOB SITE
LEGAL (❑ SEE ATTACHED SHEET)
DESCR. I
NAME / MAIL ADDRESS CITY 8 STATE LICENSE NO. PHONE
CONTRACTOR �A C
USE OF
BUILDING
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
u � 16C,
Valuation of work: $ PLAN CHECK FEE PERMIT F#��
0
SPECIAL CONDITIONS:
BEDROOMS I DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SO. FT. GARAGE ❑
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ ATTACHED ❑ OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE ❑ 1 DETACHED ❑
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR-
CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER
I certify that I am a currently registered contractor in WORK IS COMMENCED.
the State of Washington and I the
aware of the FOR OFFICE U S ONLY
ordinance requirements regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANENT ❑ SHORELINES
SEASONAL ❑ FLOODPLAIN ❑
Firm E.D. NO. S.E.P.A. ❑
Special Approvals IN OUT YES APPROVED
By NO
Lic. No.
Date ZONING
iT ANNI G DEPT
HEALTH DEPT.
OWNERS AFFIDAVIT
PUBLIC WORKS
I certify that I am exempt from the requirements of the FIRE MAR§IJAL
contract or registration law RCW 18.27, and am aware BUILDING DEPT.
of the Mason Cpunty ordinance requirements for
which this permit is issued and that all work done will ROAD ACCESS
be in conformance therewith. UMg-TPRVEHICLE PERMITfPTjED BY PLAN HECK BY APPROVED FOR ISSUANCE
o4r M Date. / U _/ BY
saw/
P CHECK VALIDATION CK. M.O. CASH P MIT VALIDATION CK. M.O. CASH
PLOT PLAN
r
ADDRESS C 3 a Gy / �' — =f; j �v�y• PERMIT NO. = o
s
x °o
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 A"D 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'
IRS
• C h
EE
i
�j c
I/We certify that the proposed construction will conform to the dimensid)u end uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNER(S) OF SITE S STRUCTURE(S) (PRINT) IONATURE OF-OWN ER(S) OR AUTHORIZED REP ESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED DATE
DISTRICT AS NOTED