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BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584 /
427-9670 DATE ISSUED 41-16 ~X r
PERMIT NC4-7/7 L
OWNER NAME MAILADDRESS CITY&STATE ZIP PHONE
3" !�/ 1� o EivI3E!�G— I - W 6?
DIRECTIONS
TO JOB SITE L,4,k- [.Ap., r l 6-9
PARCEL LEGAL
NUMBER 'O� fjZ- IDESCR.
/ V T
NAME MAILADDRESS CITY&STATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF
BUILDING
CLASS OF NEW ADDITION ALTERATION REPAIR �/� MOVE REMOVE
WORK r
DESCRIBE n
WORK VC'
I
i
I
I
BEDROOMS ;g-^ DECKS / CARPORT NOTICE
V� SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. GARAGE CONDITIONING.
NO.OF STORIES BASEMENT ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 JAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SO.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 ROW 18.2?,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.
XOWNE E �/ XBY DATE-
7-
FOR OFFICE USE ONLY
DEPARTMENT APPROVED DEPARTMENT APPROVED BUILDING VALUATION
YES NO YES NO
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING " PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP �3 PRE INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATE SURCHARGE
APPLICATION ACCEPTED BY PLANS CHECK BY A D FOR ISSUANCE PERMIT VALIDATION
IBY6a-3/ CASH MO TOTAL A5r/'