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HomeMy WebLinkAboutBLD7682 Desk - BLD Application - 10/17/1980 BUILDING PERMIT APPLICATION v � MASON COUNTY P.O. Box 186 Shelton, Washington 98584 426-5593 DATE ISSUED T NO. OWNER NAME M DDRES CITY 8 STATE ZIP PHONE DIRECTIONS _ q TO JOB SITE / � LEGAL ❑SEE ATTACHED SHEET) DESCR. NAME MAI ADDRESS CITY 8 STATE // LICENSE/NNO,.�/ PHONE � CONTRACTOR �yLvdi� 3�cS �A- it'T /3f �C/ F Tom' 77Z USE OF BUILDING ,SL--�x Cut /70 Class of work: ❑ NEW KADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE Describe work: ir�( 2 C0 /f'vu�v A Eve L Valuation of work: $ PLAN CHECK FEE PERMIT FEE SPECIAL CONDITIONS: BEDROOMS I DECKS CARPORT ❑ NOTICE BATHROOMS TOTAL SQ. FT. GARAGE ❑ ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING NO. OF STORIES BASEMENT [I ATTACHED AIR CONDITIONING. TOTAL SQ. FT. FIREPLACE ❑ 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 USE 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. ❑ By Special Approvals IN OUT YES APPROVED NO Lic. No. Date ZONING PLANNING DEPT. HEALTH DEPT. OWNERS AFFIDAVIT PUBLIC WORKS certify that I am exempt from the requirements of the FIRE MARSHAL contract or registration law RCW 18.27, and am aware BUILDING DEPT. D of the Mason County ordinance requirements for which this permit is issued and that all work done will ROAD ACCESS be i c ce therewith. MCgOR VEHICLE PERMIT APbl ICATION ACCE T D BY I PLANS CHECK BY APPROVED FOR ISSUANCE Owner Dat BY;1 , PLAN CHECK VALIDATION CK.. M.O. CASH PERMIT VALIDATION CK. M.O. CASH PLOT PLAN _ADDRESS ©/ / 19 e,9jSe"A)6- �S' . PERMIT NO. O 4 0 = s s o 0 LEGAL x DESCRIPTION LOT BLK ADDITION r 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 Al"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' _ c �f I/We certify that the proposed co ru ion Wi I agnform to tha diirNnsidns and uaea shown above and that no changes will be made without first obtaining approval. ::zj tv(,J,( NAME(S) OF OWNER(S) OF SITE a STRUCTURES) (PRINT) I AT RE OF OWNERS) OR AUTHORIZED REPRESENTATIVE DO NOT WRITE BELOW THIS LINE APPROVED�Wy_Y/_ /7/A� DATE DISTRICT AS NOTED lJT/� 7 �T2'd t/ ONELTON PRINTING