HomeMy WebLinkAboutBLD N/A Dock - BLD Application - 4/26/1985 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATEISSUED
PERMIT NO.
OWNER NAME MAIL ADDRESS CITY&STA E ZIP PHONE
C/
DIRECTIONS
TO JOB SITE -
LEGAL (❑ EE SEE ATTACH SHY
DESCR.
NAME MAIL ADDRESS CITY STATE LICENSE NO. PHONE
x CONTRACTOR
USE OF
X BUILDING
Class of work: ❑ NEW ❑ ADDITION ALTERATION XREPAIR ❑ MOVE ❑ REMOVE
Describe work:
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Valuation of work: $ r 2- PLAN CHECK FEE PERMIT Y30.5
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SPECIAL CONDITIONS:
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BEDROOMS DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SQ. FT. GARAGE ❑
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ OR 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)( SHORELINE
SEASONAL ❑ FLOODPLAIN ❑
Firm E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT.
PUBLIC WORKS
I certify that I am exempt from the requirements of the FIRE MARSHAL
contract or registration law RCW 18.27, and am aware BUILDING DEPT.
of the Mason County ordinance requirements for
which this permit is issued and that all work done will ROAD ACCESS
be in conformance therewith q MOTOR VEHICLE PERMIT
X / J PLICATION ACCEPTED BY PLANS ECK BY APPROVED FOR ISSUANCE
Owner to.
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
Reeam� lop. P�.QI' PLAN �/ r+T c aKe`'
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ADOR SS O_LzPERMIT NO. i 10
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LEGAL
DESCRIPTION LOT ff f� 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 ROLI.OWING 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 AkID 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-
1,,�ON THEREOF.
0 JIN ICATE NORTH IN CIRCLE i GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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I/We certify that the proposed construction will conform to the dimensiMs and uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNERM OF SITE d STRUCTURMCS) (PRINT) SIGNATURE OF OWNERIS) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
GMZLTON PRINTING