HomeMy WebLinkAboutBLD19354 Mobile Home - BLD Application - 9/23/1986 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
426-5593 ^/ DATE ISSUED
-,3/�e`/7 61 - /LZT�GC'� u- PERMIT NO. /7F
OWNER ME MAILADDRESS CITY&STATE ZIP PHONE
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DIRECTIONS —7 �j (� {.�
TO JOB SITE / �'Y) I �J --���V��tI I p h J A�/'ah k OG�C G�,
2D/l7/ L/
LEGAL A' /yam
CONTRACTOR NAME MAILADDRESS CITY&ST LICENSE NO. ZIP PHONE
USE OF
BUILDING
WORK O✓ NEW ADDITION _ --_ PAIR MOVE REMOVE
DESCRIBE ll
WORK
BEDROOM DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SO.FT. GARAGE CONDITIONING.
NO.OF STORIES BASEMENT ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SQ.FT. FIREPLACE DETACHED ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PERMANENT ✓ SHORELINE
SEASONAL
OWNER/SAFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGIST TION 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 ISSUED 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 CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINING APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
XOWNER ATE X BY
DATE
FOR OFFICE USE ONLY
APPROVED DEPARTMENT
DEPARTMENT APPROVED
ves No ves No BUILDING VALUATION
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING
l PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
PLANNING
PLUMBING
MECHANICAL
STATE BUILDING FEE �U
STATE SURCHARGE
LIGATION ACCEPTED BY PLANS C /C�K BY APPR,OjV�ED�FOR,l�56UANCE PERMIT VALIDATION _
C'+ MO TOTAL
PLOT PLAN
ADDRESS L Y —7✓ 7 '�[ �<<L\ �/y PERMIT NO. 4 0
= a
n >
� o
LEGAL -i
DESCRIPTION LOT BLK ADDITION n
u
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- r\
SIONS, SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION A'"D 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. 1�
C �
c�
S
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
,�� �'► 1 ( ��1a�1 '�
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1 1
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I/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.
N AME(SI OF OWN ER(S) OF SITE h STRUCTURE(S) (PRINT! SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
CHRISTMASTOWN PRINTING