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BUILDING PERMIT APPLICATION
MASON COUNTY
P. O. Box 400 Shelton, Washinqton 98584
DATE—
Applicant to complete numbered spaces only. PERMIT NO._L �P
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JOB ADDRESS
L L /�+,5 �', If 47
&/V`, � 411
1 S/7,a,., �/ /J
1 ESCR. " �� &1 /Dj�� ( SEE ATTACHED SHEET)
ai 61 A.7c I O 12
OWNER MAIL ADDRESS ^ // / PHONE
z oSNF /�63 5kf StATr� r* 1 -yl.3Z
CONTRACTOR MAIL ADDRESS PHONE LICENSE NO.
3
ARCHITECT OR DESIGNER MAIL ADDRESS PHONE LICENSE NO.
4
ENGINEER MAIL ADDRESS PHONE LICENSE NO.
5
LENDER MAIL ADDRESS BRANCH
6
USE OF BUILDING
7
8 Class of work: ❑NEW ❑ADDITION ❑ALTERATION ❑ REPAIR O MOVE EI REMOVE
9 Describe work:
10 Change of use from
Change of use to
11 Valuation of work: $
� C� PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS: Type of q Occupancy
Const. MO�t fjo,,, Group Division
Size of Bldg. No.of Max.
(Total)Sq. Ft. Stories Occ. Load
Fire Use Fire Sprinklers
APPLICATION
ACCEPTED BY PLANS CHECKED BY APPROVED FOR ISSUANCE BY. Zone Zone Required []Yes ONO
)/1( /l No.of OFFSTREET PARKING SPACES:
/ mil ���CCCJJJ IS Dwelling U n I t s Covered Uncovered
N O T I C E Special Approvals Required Received Not Required
ZONING.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEALTH DEPT.
HEATING, VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION FIRE DEPT.
AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS, OR IF CONSTRUC- OTHER (So*clfy)
TION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF
120 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
I hereby certify that I have read and examined this application and
know the same to be true and correct. All provisions of laws and
ordinances governing this type of work will be complied with whether
specified herein or not. The granting of a permit does not presume to
give authority to violate or cancel the provisions of any other state or
I
law regulating construction or the performance of construction.
SIGNATU�OCCTOR AU TN IZED AGENT (DATE)
SI GNAT R OF OW IF OWNER BUILDER (DATE)
N CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
SHELTON PRINTING CO.
j � 1
It PLOT PLAN
ADDRESS PERMIT NO.
.�Q l O/A F u
A O
LEGAL 1/ n
DESCRIPTION LOTS q-` /`/kbt Y7 B L K J / ADDITION j47 S0A)
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS J ` 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 'FHE 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 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 INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
14
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I/We certify that the proposed con ruction will conform to the di ensions and uses shown above and that no changes will be made without
first obtaining approval. ` —
7—NAIVE(S) OF WNER(S) OF SITE h STRUCTUREISI (PRINT) SIGNATURE OF NER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
GHEL7ON Pr?TN7t1,'3