HomeMy WebLinkAboutBLD11295 Addition - BLD Application - 8/25/1981 BUILDING PERMIT APPLI
CATION
TION
10
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 _
DATE ISSUED__
PERMIT NO. _ /�a29cSJ
PBUILDING
E� MAIL ADDRESS CITY&STA E ZIP PHONE
S
E
� ( SEE ATTACHED SHEET)
NAME AIL ADDRESS
OR CITY&S ATE LICENSE NO. PHONE
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work: .-
(/.ieCJe
Valuation of work: $ 4�j �JL�Q PLAN CHECK FEE PERMIT FEE
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SPECIAL CONDITIONS:
BEDROOMS I DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SO. FT. GARAGE ❑
NO. OF STORIES BASEMENT ❑ ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
TOTAL SO. FT. FIREPLACE ❑ DETACHED ❑ OR AIR CONDITIONING.
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
1 certify that I am a currently registered contractor in WORK IS COMMENCED.
the State Of Washington and I am aware of the
ordinance requirements regulating the work for which FOR OFFICE USE ONLY
the permit is issued and all work done will be in
conformance therewith. PERMANENT ❑ SHORELINES ❑
Firm SEASONAL ❑ FLOODPLAIN ❑
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
certify that I am exempt from the requirements of the FIRE MARSHAL
contract or registration law RCW 18.27, and am aware
of the Mason County ordinance requirements for BUILDING DEPT.
whi h this permit is issued and that all work done will ROAD ACCESS
X b in conformance therewi h. MOTOR VEHICLE PERMIT
OWE ICATION AC EPTED BY PLANS CHECK BY ROVED FOR SUANCE
t Y
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION K. M.O. CASH
y111 C)
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PLOT PLAN
ADDRESS PERMIT NO. g
G )-,P,A f O ems►
LEGAL
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DESCRIPTION 134k. a � TK !o � k� 4- TR. .lsf."IF Z ,*-T,1. �
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 AND SEWER SERVICE ELEVATION. SHroW 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.
RO/X1.Of
0 INDICATE NORTH IN CIRCLE
N.
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I/We certify that the proposed construction will conform;to the dimensidns and uses shown above and that no changes will be made without
first obtaining approval.
NAME(:) OF OWNER(:) OF SITE s STRUCTURE(S) (PRINT) SIGNATURE OFOWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE