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Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING Attic OTHER
Groundwork
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
MIS
MASON 9OUNTY
MISCELLANEOUS PERMIT APPLICATION
PLEASE PRINT 426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670
S
#1 O er y��tC �S � �,QG q 3_07�if WK. Phone# �� `-V�2 _145 Fire District
Site Address �h /21 �� c'�D e,Y City
Mail Address
City ":�)]f ya_no St 0J�- Zip 98 T 8-</
Applicant Phone#
Applicant Address
City St Zip
Directions to Site: l Q 1 Sa `"U�k b bAy Thz 2 Pop-+ '_� -�—u2o Lcr—1
[7C�-1 ( 0 W I'AvTCA1 t2�ffZ -}�-c`iAL �c� �AS� 1f�1A,1 •�� � STi97r
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#2 el No. `2 ��0�3
regaDescription - v�i3� IJCJ
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site: _
saltwater lake river creek stream pond wetland seasonal runoff marsh other
#4 Project Start Date J—U N Project Completion Date OCT
#5 Use of Buildiing Describe proposed construction
STAN �4R� S f N S�cv _1:-n07-i•v5 AAD D
'Depending upon the type of permit,a floor plan and plot plan may be required.
'This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON-
MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT-
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND
IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE-
FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUZRSININGAPPROVALFROMTHEBUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEP MENT.
X OWNE �.- (� X BY
DATE DATE
Show following on the site plan
l
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL USE ONLY:Accepted by. ! Dater
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building �LL
Fire Marshal
Other
Special Conditions Fees
Permit Fee $ ��
Plan Check
Other
Other
State Building Fee �F
TOTAL DUE $