HomeMy WebLinkAboutBLD16669 - BLD Application - 4/11/1985 I
BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 r7/ D —
DATEISSUED C CJ _
PERMIT NO. 4,
OWNER NAME MAIL AD S CITY&STATE PHONE
*AMA6M Itb t/O
DIRECTIO S IF
TO JOB SITE .*
LEGAL / / (❑ SEE ATTACHED SHEET)
DESCR. S
CONTRACTOR NAME MAIL ADDRESS CITY a STATE LICENSE NO. PHONE
USE OF
BUILDING O/7/) a
Class of work: NEW��++❑��A''DDITION ❑ ALTERATION ❑ REPAIR G_MOVE ❑ REMOVE
Describe work: �/ �� v P716 0
!�/ /►/' ® O�' A/Y
Valuation of work: $ y'/ PLAN CHECK FEE PERMIT FEE 00
SPECIAL CONDITIONS:
aira r a� r�� 1
GU;r� 7?�oalu/a r
BEDROOMS DECKS CARPORT NOTICE
BATHROOMS TOTAL SO. FT GARAGE ❑ SEPARATE PERMITS
NO. OF STORIES BASEMENT ❑ ATTACHED ❑ OR AIR CONDITIONING.
RE REQUIRED FOR PLUMBING, HEATING. VENTILATING
TOTAL SO. FT FIREPLACE ❑ DETACHED ❑
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR
ONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FORA 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 FOR OFFICE U S ONLY
ordinance re uirements regulating the work for which
j the permit s Issued and all work done will be in
conforman a therewith. PERMANENT SHORELINES
SEASONAL FLOOOPLAIN ❑
Firm E.D. NO. S.E.P.A. ❑
APPROVED
By Special Approvals IN OUT YES NO
Lic. NO Date ZONING
PLANNING DEPT.
t
OWNERS AFFIDAVIT HEALTH DEPT. rjy�
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
a of the Mason County ordinance requirements for BUILDING DEPT.
which this permit is Issued and that all work done will ROAD ACCESS
3 be in conformance the ith. MOTOR VEHICLE PERMIT
PP CAT ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
7 Owner Date *z# A2A<f BY
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS ( � /-� �I / t^i 1-i 14 tl' l <' PERMIT NO
LEGAL 'o
DESCRIPTION LOT BLK ADDITION
[
SITE AREA_� ( C' Sq.Ft, AREA OF SITE OCCUPIED BY BUILDINGS �^ -
_Sq.Ft.: tf
INSTRUCTIONS TO APPLICANT
FILED WITH PERMIT APPLICATION. (EACH BUILDING SITE MUST HAVE A SEPARATE PLOT PLAN.)
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN 1"-20 ARE
FOR NEW BUILDINGS PROVIDE THE FOLLOWING INFORMATION IN THE SPACE BELOW: LOCATIO OF
PROPOSED CONSTRUCTION AND EXISTING IMPROVEMENTS.SHOW BUILDING,SITE,AND SETBACK D EN- '
NS.SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET LEVA• o '
TI ['D SEWER SERVICE ELEVATION. SHOW LOCATION OF WATER, SEWER, GAS AND E TRICA-
S 0 VIC ES.SHOW LOCATION OF SURVEY PINS.SPECIFY THE USE OF EACH BUILDING AND AJOR POR-
TION THER
�p GCIZ/ILIi� (J /-Jos �' 0
INDICATE NORTH IN CIRCLE V� GRAPH SQUARES ARE 5' X 5' OR 1"-20'
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I/We certify that the proposed construction will conform to the dimensiohs end uses shown above and that no changes will be made without
first obtaining approval.
N•ME(S OP OWN R P a1T[ a STRUCTUK•[T✓�{nf RIN TI ION TUR OP OWNERI31"OR AU TH IZED R E ENT�TiVE
DO NOT WRfTE BELOW THIS LINE
DISTRICT APPROVED
ASNATED DATE
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