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MESSAGE DATE b REPLY DATE
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SIGNED SIGNED
REDIFDRM® 4S 473 SEND PARTS 1 AND 3 WITH CARBON INTACT -
PART 3 WILL BE RETURNED WITH REPLY. PIXY PAR ISO SETS)0 473
DETACH AND FILE FOR FOLLOW-UP
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BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 9858���j7
426-5593
DATEISSUED
PERMIT NO.
NAM�E1 MAIL/ADDRESS , /� CITY 3 STATE ZIP PHONE
OWNER GG; /v.L� .Z2-30 4 V, � 14e4 S.
DIRECTIO 17y—35- 7 3
TO JOB 4rfE
LEGAL (❑ SEE ATTACHED SHEET)
DESCR.
NAME MAIL ADDRESS CITY 6 STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING
Class of work: EW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
Valuation of work: $ PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS:
BEDROOMS {DECKS CARPORT L; NOTICE
BATHROOMS I TOTAL SQ. FT. _ GARAGE Ll
ATTACHED L] SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE Li 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 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 ONLY
ordinance requirements regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANENT ;] SHORELINES 1:1
SEASONAL ❑ FLOODPLAIN ❑
Firm E.D. NO. S.E.P.A. I
By Special Approvals IN OUT YES APPROVED NO
Lic. No. 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
of the Mason County ordinance requirements for BUILDING DEPT.
which this permit is issued and that all work done will ROAD ACCESS
be in conformance therewith. MOTOR VEHICLE PERMIT
APPLICATION ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
Owner Date BY
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS PERMIT NO. �/�! 0 o
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LEGAL
DESCRIPTION LOT BILK ADDITION u
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS Sq. Ft.
r. INSTRUCTIONS TO APPLICANT
e�
R THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SCALE OF NOT LESS THAN 1"=20' ARE
T 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 P"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. r
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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I/We certify that the proposed construction will conform to the dimensi and uses shown above and t t no changes will be made without ,
first obtaining approval.
NA (3) OF OWNER(S) OF SITE b STRUC TUR E(S) (PRINT) IGNAT E OF OWNERS) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW T S LINE
APPROVED
DISTRICT AS NOTED DATE
6HELTON PRINTING