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WILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 p
DATE ISSUED
o PERMIT NO.
OWNER NAME MAIL ADORE CITY 6 STATE ZIP PHONE
Dr. L i e
DIRECTIONS
TO JOB SITE J�,� / G lde/SIG 2-
LEGAL (❑SEE ATTACHED SHEET)
DESCR.
NAME MAIL ADDRESS CITY 6 STATE LICENSE NO. PHONE
CONTRACTOR &
E
USE OF
BUILDING
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
G �
Describe work: , V
Valuation of work: $ PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS: fo
BEDROOMS DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SO. FT. GARAGE ❑
NO. OF STORIES BASEMENT❑
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
OR AIR CONDITIONING.
TOTAL SO. FT. FIREPLACE lioTo" DETACHED ❑
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED
CONTRACTOR AFFIDAVIT IS NOT COMMENCED WITHIN 120 DAYS, OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER
I certify that I am a currently registered contractor in WORK IS COMMENCED.
the State ofWashington and i aware of the FOR OFFICE USE ONLY
ordinance requirements
the regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANENT ❑ SHORELINES ❑
/J
A C (� �S /P j/G-� �d A� SEASONAL ❑ FLOODPLAIN ❑
Firm E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT
YES APPROVED NO
Lic. No. �' 3 ' (J l ate _ y— 9 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
Abe in conformance therewith. MOTOR VEHICLE PERMIT
Date. APPLICATION ACCEPTED BY PLANS CHECK BY AAPROVED FOR ISSUANCE
N �`H
.VALIDATION CK M.O. CASH PERMIT VALIDATION M.O. CASH
r,r .