HomeMy WebLinkAboutBLD15642 Mobile Home 12x60 - BLD Application - 6/7/1984 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATE ISSUED --1—,Or _
�rcrr7C� .�/x�f�pfj PERMIT NO.
OWNER NAME D MAIL ADDRESS CITY&STATE ZIP PHONE
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DIRECTIONS
TO JOB SITE YAR& O-
LEGAL (0 SEE ATTACHED SHEET)
DESCR. iY6T11 ? l/
CONTRACTOR NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
USE OF '
BUILDING S / � / 167
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
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lie, 04,01
Valuation of work: $ PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS:
BEDROOMS I DECKS CARPORT ! I NOTICE
BATHROOMS TOTAL SO. FT. GARAGE
AT L_ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ OR AIR CONDITIONING.
TOTAL SO. FT. FIREPLACE :-: DETACHED
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR-
CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FORA PERIOD OF 180 DAYS AT ANYTIME AFTER
I certify that I am a currently registered Contractor in WORK IS COMMENCED.
the State of Washington and I the
aware of the FO OFFICE USE ONLY
ordinance requirements regulating the work for which
She permit is issued and all work done will be in
)conformance therewith. PERMANENT SHORELINES/
SEASONAL I_ FLOODPLAIN I_I
Firm
E.D. NO. S.E.P.A. f_7
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT. eir
_ / s .
PUBLIC WORKS
I certify that I am exempt from the requirements of the FIRE MARSHAL
contract or registration law RCW 18.27, and am aware BUILDING DEPT.
of the Mason County ordinance requirements for
which this permit is issued and that all work done will ROAD ACCESS
be in�y conformance therewith. MOTOR VEHICLE PERMIT
/// w J AP ICAO ACCEPTED BY PLANS CHECK BY ROVE OR ISSUANCE
Owner ✓/ Date
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. ASH
PLOT PLAN
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ADDRESS �� �� a /� S� �(/I/y �! PERMIT NO. f
I� D
a o
LEGAL N
DESCRIPTION LOT �� BLK ADDITION
SITE AREA / 2-0 Sq.Ft. AREA OF SITE OCCUPIED BY BUILDINGS U 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 BUI LDING,SITE,AND SETBACK DIMEN-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION A"ID 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.
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X,5' OR 1"=20'
O \
I/We certify that the proposed con fuction will conform to the dimensions and uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNER(SI OF SITE 6 STRUCTURE(S) (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
GHELTON PWNTIN^u