HomeMy WebLinkAboutBLD N/A Pre-Inspection - BLD Application - 4/5/1990 BUILDING PERMIT APPLICATION
' MASON COUNTY
DEPARTMENT of GENERAL SERVICES
i P.O. BOX 186 SHELTON, WASHINGTON, 98584
427-9670 DATE ISSUED
PERMIT NO.
OWNER Zzg&�
E MAILADDR CITY3STATE ZIP PHONE-a/ SE
DIRECTIONS A g7
TO JOB SITE �V
PARCEL LEGAL
NUMBER DESCR.
NAME MAILADDRESS CITY 3 STATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF
BUILDING �(SC
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK r
DESCRIBE
WORK
BEDROOMS DECKS CARPORTS NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. GARAGE `!� CONDITIONING.
NO.OF STORIES J P 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.SO.. FIREPLACE QS 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
REGIST TION LAW RCW 18.27,AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIR MENTS FOR WH IS PERMIT IS ISSUED AND THAT ALL WORK DONE WILL BE WORK FOR WHICH THE PERMIT IS 138UED AND ALL WORK DONE WILL BE IN
IN CO ORMANCE NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINI APP F E B G DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X 0,411
R SAO t DATE �3 X BY DATE
FOR OFFICE USE ONLY
DEPART ENT APPROVED DEPARTMENT APPRQVED BUILDING VALUATION
YES NO YES NO
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O. BUILDING PLAN CHECK
INSPECTION
RELINE
ay ODSTOVE
NOMMiNUMBING
MECHANICAL
STATE BUILDING FEE
STATE SURCHARGE
APPLICATION ACCEPTED SY P CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION
TOTAL
BY CASH CK MO
r � ,
PLOT PLAN
AO D PERMIT NO.
f
LEGAL
DESCRIPTION LOT SLK ADDITION g
SITE AREA ViSOSq.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;,BUILDIN PROVIDE THE FOLLOWING INFORMATION IN THE SPACE KI M: LOCATION OF
PROPOSEV CONS`t'R ION AND EXISTING IMPROVIIMENTS:SHOW BUILDING,SITE,ANO;SETBACK DIMEN-
SIONS %.SHOW, FINISH CONTOURB Oft OIAINAGE:'FIRST FLOOR ELEVATION, STREET. ELEVA-
TION AND SEWER BEFMVVJCE ELEVATION. SNOW LOCATION OF WATER, SEWER; GAS_AND`ELECTRICAL
SERVICE LINES.SHOW LOCATION OF SURVEY PINS.SPECI THE USE OF EACH BUILDING.AND MAJ7zA
TION THEREOF. �Al c
12w
/S
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE W X W OR 1"-20'
l°
Al-
1/00
1
I/YW certify that the con itruction will conform to the dimenfionf and wfs shown above and that no ►qef will be made without
first obtaining approval.
ell 4! m/w ►
NA wma" 1 Of SIGNATURE OFN 1 UTHGRIZKO
Do Nor wwre mow rNis LING
APPROVED
DISTRICT AS NOTED DATE