HomeMy WebLinkAboutBLD28619 SFR - BLD Application - 7/18/1991 - 1
BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
426 W.CEDAR/P.O. BOX 186 SHELTON,WASHINGTON 98584 _l
427-9670 DATE ISSUED
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PERMIT NO.
NAME MAIL ADDRESS CITY SSTATE ZIP PHONE
OWNER R.10Aao -Iles ��. g� ��� �/,cT,� lr/q der
DIRECTIONS
TO JOB SITE i4uov ( Q
.ESCRPARCEL 7NUMBER CZD1Z Z gGD /
NAME MAIL ADDRESS CITY 6 STATE ZIP PHCNE LICENSE NO.
CONTRACTOR
USE OF
BUILDING �(� rj E1VA C-
CLASS OF NEW ADDITION ALTERATION REPAIR TMOVE REMOVE
WORK r
DESCRIBE
WORK
a
AREA: a3 NUMBER OF: PLEASE INDICATE: NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
RESIDENCE r SgFt STORIES SHORELINE Cl CONDITIONING.
BASEMENT SgFt BEDROOMS PRIMARY RES4 THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
DECKS J VC- S Ft BATHROOMS Z SEASONAL RES.❑ COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
g ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED,
CARPORT SgFt FIREPLACE IS CARPORT/GARAGE
GARAGE SgFt ATTACHED❑DETACHED❑
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT 1 AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGISTRATION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIREMENTS FOR WHICH THIS PERMIT IS I UED AND THAT ALL WORK DONE WILL BE WORK FOR WHICH THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
IN CONFORMANCE THEREWITH. NO C GES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINING APPROVAL F HE B P RTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X OWNE DATE X BY_ _ DATE
FO OFFICE USE ON LY
DEPARTMENT APPROVED DEPARTMENT APPROVED BUILDING VALUATION
YES NO YES NO
HEALTH PUBLIC WORKS FEE
PLANNING i FIRE MARSHAL BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
-APPLICATION ACCEPTED BY gNS CHHE�CK BY APP OVED F ISSUAN PERMIT VALIDATION
1' '�� � CE BY r CASH CK MO
TOTAL �� J
5.Gore= C.�q
the
,twx
as
assessor-
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We have rceeatly ceceive•d a cog? of Csx c:r=ificaca for atobil* home
r 'vemeac on your mobil* he=*.
Ia order cbac vs msy-accurately values you oobile hoot, pleasa eaapleCe
the questions below and return this foci to Our office by .
Zz is imperative that this tatarmatiaa be p3sd_ty preveat s
poasibla double ass+sss*ct. '
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BUILDING PERMIT PLOT PLAN
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. Box 186 SHELTON, WASHINGTON 98584
427-9670 DATE ISSUED
PERMIT NO.
NAME MAiLA 0 SS CIi 3 STATE ZIP PHONE
OWNER n p ,;
OIRECTICNS
TO roe SITE �,�, to/ 0 5W"C A s- 1191
5�ELTA.r S�aA.. =s !zn
PARCEL ' LEGA L / ra
NUMBER I�ZU 1'2 Z j jOr qSj OESCA. I - 7-C e t S�o.zT P47- /F1!5J
Indicate SPIew. ;��,Zasefnents
rooerty lines and dimensions.and roads.
�eptic, drainfield and reserve area, or sewer.
eptic tank and drainfield setback distances from foundations.
Cr ocation of proposed construction on property.
M- ell
ilding & septic system setback distances from all property lines & easements.
Indicate North and water line.
O,saltwater, lakes, rivers, streams, wetlands, drainage.
In Circle Cj Attach copy of septic system"as built" or septic permit"approval.
C5'Indicate topography profile of property and structure on reverse side.
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TOPOGRAPHY PROFILE OF PROPERTY AND LOCATION OF STRUCTURE
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