HomeMy WebLinkAboutBLD13795 - BLD Application - 4/1/1983 B U IL D ING PERM I T A PPL ICA TIQN
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 y/f&—a
DATE ISSUED
PERMIT NO. �
OWNER NAME MAIL ADDRESS CITY&STATE ZIP PHONE
L t..- d Q Jy 4
DIRECTIONS
TO JOB SITE L
LEGAL (0 SEE ATTACHED SHEET)
E DESCR. r k o T N1�`1 L 5 rC
NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING
Class of work; - El NEW C ADDITION 11 ALTERATION 1-71 REPAIR E7 MOVE 0 REMOVE
Describe work;
a Ui IJ4 ,AA �
Valuation of work; $ � �i PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS;
- SP
BEDROOMS DECKS _ CARPORT ❑ NOTICE
BATHROOMS TOTAL SQ, FT. _ GARAGE
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO, OF STORIES _ BASEMENT Q OR AIR CONDITIONING,
TOTAL SQ. FT. I FIREPLACE 0 DETACHED 0
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 am aware of the
ordinance requirements regulating the work for which F O R OFFICE USE ONLY
the permit is issued and all work done will be in N - -
conformance therewith. PERMANENT SHORELINES Q
SEASONAL C7 - FLOODPLAIN El
Firm `�
- - E.D. N0. --- S,E.P,A. Q
Spacial Approvals IN OUT YES APPROVED NO
Lic. No, - -- — -- _ Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT, t/
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.
which this permit is issued and that all work done will ROAD ACCESS
be In conformance therewith. MOTOR VEHICLE PERMIT
CATION ACC TED Y PLANS CHECK BY ROVED FOR ISS ANCE
Owns r Date.
PV CHECK VALIDATION CK, M.O. CASH PERMIT VALIDATION CKJ M.O. CASH
PLOT PLAN
ADDRESS W 76 ( P E:L- li �C t?D PERMIT NO. 4 0
= o
n s
a o
LEGAL
DESCRIPTION tp �'.3 LOT �(p__ � ��"r" BLK ADDITION n
u
SITE AREA 32 20 0 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 AMD 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.
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
f3 —
70,
1/We certify that the proposed construction will conform to the dimensions and uses shown above and that no changes will be made without
first obtaining approval
NAMES) OF OWNER(S) OF SITE & STRUCTURE(S) (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
SHELTON PRINTING