HomeMy WebLinkAboutBLD10708 Dock - BLD Application - 6/4/1981 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATEISSUED
PERMIT NO. 76V
OWNER N E .. MAIL ADD ESS C & AT ZIP
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DIRECTIONS ' (` AA t
TO JOB SITE /Z I�t� l ® _ �- M, L Cam_
LEGAL /� ./n� ` / n SEE ATTACHED SHEET)
D ESCR. !�/`�"C `N is 1�/ Y�t� T� �vl�-1
NAME AIL ADDRESS CITY 6 STATE LICENSE NO. PHONE
CONTRACTOR Q� �r-
USE OF O�
BUILDING
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION AREPAIR ❑ MOVE ❑ REMOVE
Describe work: do
Valuation of work: $ PLAN CHECK FEE r ' PERMIT_F�E
SPECIAL CONDITIONS: 6 (J N �f �(J
BEDROOMS DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SO. FT. GARAGE ❑
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ OR AIR CONDITIONING.
TOTAL SO. 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 F R OFFICE USE ONLY
ordinance requirements regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANEN SHORELIN
oc
SEASONAL FLOODPLA ❑
Firm E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT. �j g
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
of the Mason County o finance requirements for BUILDING DEPT.
which this permit is issU and that all work done will ROAD ACCESS
be ' conf ma ce th ith. MOTOR VEHICLE PERMIT
\ PLIC I A rTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
Own Date B1�
AN CHECK VALIDATION CK.. M.O. CASH PERMIT VALIDATIO , M.O. CASH
" PLOT PLAN
ADDRESS PERMIT NO. 0 o
a a
R >
a o
a
LEGAL "
DESCRIPTION LOT BLK ADDITION a
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 P"ID 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.
0 INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
I/We certify that the proposed construction will conform to tM dimensiotu end uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNERS)OF SITE • STRUCTURE(S) (PRINT) SIGNATURE OF OWNERS) OR AUTHORIZED R P ESEN A IVE
DO NOT WRITE BELOW THIS LINE
APPROVED A���//��, DATE
DISTRICT AS NOTED
•HtLTON PRINTING