HomeMy WebLinkAboutBLD21356 Chimney Repair - BLD Application - 12/28/1987r 1
BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
426-5593 DATE ISSUED'---�-2Z 4 /
PERMIT NO.`--22/N 3 56
NAME MAIL ADDRESS / CITY 8 STATE ZIP PHONE
OWNER ,
7
DIRECTIONS i
TO JOB SITE Az-
PARCEL /i LEGALJ�)
N U M B E R 3as�y��y DC� � DESCR -
NAME MAILADDRESS CITY TATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF I
BUILDING
CLASS OF NEW ADDITION ALTEt,� LON REPAIR MOVE REMOVE
WORK ✓
DESCRIBE
WORK // -1
BEDROOMS DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.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,
OWNERAFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTI THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
RE GIST TION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIR MENTS 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 COFORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
O�TAI ING APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X NE�� ' 1' /6 A I E X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT YES
PPROVENo DEPARTMENT YESPPROVENO BUILDING VALUATION
- - ---�
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATESURCHARGE
APPLICATION ACCEPTED BY I PLANS CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION
TOTAL
BY CASH CK MO