HomeMy WebLinkAboutBLD8682 Pole Bldg - BLD Application - 7/21/1978 BUILDING PERMIT APPLICATION .�
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593 fy
DATE ISSUED
0 PERMIT NO. ��
OWNER NAl E MAIL ADDRESS CITY&STATE ZIP PHONE
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DIRECTIONS
TO JOB
LEGAL (❑ SEE ATTACHED SHEET)
DESCR.
CONTRACTOR
NAME MAIL ADDRE S CITY&STATE LICENSE NO. PHONE
J �
USE OF
BUILDING
Class of work: NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
Valuation of work: $ PLAN CHECK FEE PERMIT FEE ��// O"d
�v'
SPECIAL CONDITIONS:
64' OF
BEDROOMS DECKS CARPORT ❑ NOTICE
BATHROOMS TOTAL SO. FT. GARAGE ❑
NO. OF STORIES BASEMENT ❑
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE ❑ DETACHED El
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED
CONTRACTOR AFFIDAVIT IS NOT COMMENCED WITHIN 120 DAYS, OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FOR A PERIOD OF 120 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 LJ SHORELINES I I
SEASONAL 1 1 FLOODPLAIN Ll
Firm E.D. NO. S.E.P.A. f
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 BUILDING DEPT.
of the Mason County ordinance requirements for
which this permit is issued and that all work done will ROAD ACCESS
be in conformance therewith. MOTOR VEHICLE PERMIT
APPLICATION AC EPTED BY PLANS CHECK BY PROV�D FOR IS UA�10E
Ow r Date.
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS ds r. ��xi--� � �fJ)1 F�yTB� PERMIT NO.
LEGAL
DESCRIPTION LOT �S' ? � ADDITION
SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS 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 BUILDING,SITE,AND SETBACK DIMEN-
SIONS. SHOW EASEMENTS, FINISH CONTOURS OR DRAINAGE, FIRST FLOOR ELEVATION, STREET ELEVA-
TION Al"D 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.
0 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 dimensions and uses shown above and that no changes will be made without
first obtaining approval.
NAMES) OF OWNER(S1 )F ITE & STRUCTURE(S) (PRINT) SIGNATURE OFT OWNER(S) O AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED *�ge
DISTRICT AS NOTED DATE
1 6H ELl'ON PRINTN3