HomeMy WebLinkAboutBLD9943 Mobile Home - BLD Application - 8/13/1976 /D h?a 7`
BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
DATE ISSUED ' 1,3 76
PERMIT NO. 9 g'$49
OWNER NAME MAIL ADD SS CITY&STAT ZIP PHONE
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DIRECTIONS
TO JOB SITE _
LEGAL �Q 7 r C (❑SEE ATTA HED SHEET)
DESCR. bZI 3 ._ / �J .✓ &i, —//
CONTRACTOR NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
USE OF
BUILDING
Class of work: NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Descri a work:
Valuation of work: $ PLAN CHECK FEE PERMIT FEE XQ
SPECIAL CONDITIONS:
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APPLICATION, PTED BY, P NS HECK 8Y4:iL11W11V FOR IS UANCE Type of Occupancy Division
Const. Group
Size of Bldg. No. of Max.
(Total) Sq. Ft. Stories Occ. Load
CONTRACTOR AFFIDAVIT
PERMANENT SEASONAL E.D.NUMBER
I certify that I am a currently registered contractor in RESIDENCE
the State of Washington and I am aware of the MOBILE HOME
ordinance requirements regulating the work for which
the permit is issued and all work done will be in Special Approvals Required Received Not Required
conformance therewith. ZONING
HEALTH DEPT.
Firm PUBLIC WORKS
By ROAD DEPT.
Lic. No. Date
OWNERS AFFIDAVIT
I certify that I am exempt from the requirements of the N O T I C E
contract or registration law RCW 18.27, and am aware
Of the on County ordinance requirements for SEPARATE PERMITS ARE REQUIRED, FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
whic his permit is issued and that all work done will
be co formance ther ith. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED
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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
Own �te WORK IS COMMENCED.
CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
lot
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• PLOT PLAN
ADDRESSi-- �' /� PERMIT NO.
LEGAL
DESCRIPTION LOT BLK 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 A"'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 POW
TION THEREOF.
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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I/We certify that the proposed construction ,rill conform to the dimensions and uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNER(S) 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 PRINTIN-