HomeMy WebLinkAboutBLD251 Mobile Home - BLD Application - 9/5/1979 BUILDINGr 'PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATEISSUED Ss� 7 9
PERMIT NO.
OWNER ME MAI ADDRESS ITY&STATE ZIP PHONE
DIRECTI NS -t- -' �L
TO JOB SITE !iU' M� ,��• ILAff 2 ®— G,,� C dot?
LEGAL �1 /( SEE ATTA ED SHEET)
DESCR. - a � � Zf ' 1 lie
CONTRACTOR NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
USE OF
BUILDING
Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe wor4K: j
Valuation of work: $y�r L 'I PLAN CHECK FEE PERMIT FEE
Cr
l G''ZZ99
SPECIAL CONDITIONS:
BEDROOMS DECKS ,CARPORT ❑ NOTICE
BATHROOMS TOTAL SQ. FT. GARAGE ❑
NO. OF STORIES BASEMENT ElATTACHED ❑ 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 SHORELINES ❑
SEASONAL❑ FLOODPLAIN ❑
Firm
E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT. A-V �
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 ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
Own Date.
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
{
PLOT PLAN
ADDRESS PERMIT NO. f o
z o
n f
s o
0
LEGAL a
DESCRIPTION LOT BLK ADDITION "u
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 P"'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.
INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
t
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.
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
6HEI-TON PRINTING ,