HomeMy WebLinkAboutBLD18223 Pre-Inspection Roof Change - BLD Permit / Conditions - 1/6/1986 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 p/
DATE ISSUED
PERMIT NO.
OWNER NAME MAIL ADDRESS CITY d STATE ZIP PHONE
DIRECTIONS
TO JOB SITE
LEGAL (( SEE ATTACHED SHEET)
DESCR
NAME MAIL ADDRESS CITY 3 STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING { C14A C
Class of wo ❑ ADDITION ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
r's,cribe work:
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Valuation of work: $ PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS:
BEDROOMS DECKS CARPORT � NOTICE
BATHROOMS TOTAL SO. FT. GARAGE EI"'
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
S El NO. OF STORIES BASEMENT OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE ❑ DETACHED [I
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 FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER
I certify that I am a currently registered contractor in WORK IS COMMENCED.
the State of Washington and I the
aware of the FOR OFFICE USE N LY
ordinance requirements regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANENT C] SHORELINES
Firm SEASONAL ❑ FLOODPLAIN [I
/ w E.D. NO, S.E.P.A. L'
B ooO��G. �' .S ,L 1�1�7 �F'r Special Approvals IN OUT YES APPROVED NO
L1c. No.StjfoA2 C X 'Inn 0'y Date !— ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT.
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
b in conform nce therewith. MOTOR VEHICLE PERMIT
(� ^�Owner Date. APPLI TION ACCEPTED BY PLANS HECK BY APPROVED OR ISSUANCE
.1/a' � � •—d�' �
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
CHRISTMASTOWN PRINTING
PLOT PLAN
A_ DDRESS & Z/Zl) ,�. �i.L t/'cL� �!�` PERMIT NO � o
LEGAL :
DESCRIPTION LOT BLK ADDITION u
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS-��';✓t= C Sq. Ft.
INSTRUCTIONS TO APPLICANT n
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN 1"=20' ARE y V
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-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION ARID 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. "
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INDICATE NORTH IN CIRCLE � GRAPH SQUARES AREA' OR 1" Ilk'
pt-5r -7S_ re, til>=xT-
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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.
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NAME(S) OF OWNER(3) OF SITE h STRUCTURE(3) (PRINT) SIGNATURE OF O ER(3) OR AUTHORIZED REP ESE T T I V E
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
CHRISTMASTOWN PRINTING