HomeMy WebLinkAboutBLD0486 Changing Covered Entry - BLD Application - 1/20/1987 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
426-5593 DATE ISSUED L<:7
PERMIT NO.
NAME MAILADDRESS CITY&STATE ZIP PHONE
OWNER c 1
DIRECTIONS
TO JOB SITE
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LEGAL ,,
DESCR.
NAME M ILADDRESS &STAT LICENSE NO. -zo- PHONE
CONTRACTOR � - 5riz Z
USE OF
BUILDINGS , �o c
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK
DESCRIBE /
WORK C c+r<<• . 'A i 7 ,,1 " aL
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BEDROOMS DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. GARAGE CONDITIONING.
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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. j-LiL FIREPLACE DETACHED ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PERMANENT SHORELINE
SEASONAL
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGISTRATION L RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIREMENTS R 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 CONFORMA E THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINING APP VAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X OWNER DATE X BY LSL DATE
FOR OFFICE USE ONL
DEPARTMENT APPROVED DEPARTMENT YES NO APPROVED 7 BUILDING VALUATION G
YES NO � ��,
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK e'
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
PLANNING
PLUMBING
MECHANICAL
STATE BUILDING FEE 5
STATE SURCHARGE
PLICATION ACCEPTED BY I PLLAANSS CCH CK BY APPROVED
DFFOR ISSUANCE PERMIT VALIDATION
Llr�.c Ij BY Zl G�r CASH CK MO TOTAL 7�QV
PLOT PLAN
ADDRESS 1-�>c' Cv--r� �1- rr�y PERMIT NO.
0
LEGAL
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DESCRIPTION LOT BLK ADDITION r�
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SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS Sq. Ft. t
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 BUILDING,SITE,AND SETBACK DIMEN-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION AND 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 It
-
a
TION THEREOF. \
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INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' 5' OR 1"=20'
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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 b We without
first obtaining approval. ^ We without
NAIAEIS) OF OWNER($) OF SITE 6 STRUCTURE(S) (PRINT) SIGNATURE OF OWNER($) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED `'� �� DATE