HomeMy WebLinkAboutBLD12343 Mobile Home - BLD Application - 4/28/1982 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 e_a�' g a
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u DATE ISSUED (�
PERMIT NO. ' I3
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OWNER NAME MAIL ADDRESS CITY&STATE ' + ZIP ONE PH
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DIRECTIONS
TO JOB SITE _
LEGAL �/ 7' (C] SEE ATTACHED SHEET)
DESCR. 4 t `"1' ,L� '�' ,pc , .Z / D
NAME 0 MAIL ADDR S CITY&STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING
Class of work: ❑ NEW aD ADDITION ❑ ALTERATION ❑ REPAIR MOVE ❑ REMOVE
Describe work:
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Valuation of work: $ I PLAN CHECK FEE PERMIT FEE Moo
SPECIAL CONDITIONS:
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BEDROOMS I 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 ORICONSTRUCTION AUTHOR-
CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FORA PERIODOF 180 DAYS AT ANYTIME AFTER
I Certify that I am a currently registered contractor in WORK IS COMMENCED.
the State of Washington 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 - SHORELINEsniµf
SEASONAL ❑ FLOODPLAIN ❑
Firm E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
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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 they with. MOTOR VEHICLE PERMIT
f/8'L, AP LIGATION ACCEPTjrD BY PLANS ECK BY APPROVED FOR ISSUANCE
Owner - Date
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CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
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PLOT PLAN
ADDRESS PERMIT NO. a°
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LEGAL
DESCRIPTION LOT BLK ADDITION 'a
SITE AREA • Sq.Ft. AREA OF SITE OCCUPIED BY BUILDINGS--Sq.Ft.
I INSTRUCTIONS TO APPLICANT
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN t"=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.DIIyIEN-
SIONS.SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION P"D 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-
TION THEREOF.
OINDICATE NORTH IN CIR CLELjr GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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I/We certify that the proposed construction will conform to the dlmensldns and uses shown above and that no changes will be mile without
first obtaining apprwel.
N MEISI O OWN ER(S) OF SITE S STRUCTUREISI (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REP ES EN T4 TIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
YH[LTON pRINTINO