HomeMy WebLinkAboutBLD26723 Mobile Home - BLD Application - 1/22/1999 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
427-9670 DATE ISSUED-
PERMIT NO.
ME MAIL ADDRESS CITY&STATE ZIP PHONE
OWNER E ' Q
DIRECTIONS
TO JOB SITE e /� r'd -prom /J
�us7 been clpipd a
PARCEL LEGAL �O
NUMBER 3 _ DESCR.
NAME MAIL ADDRESS CITY&STATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF
BUILDING
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE �� REMOVE
WORK ✓
DESCRIBE �L
WORK
BEDROOMS DECKS YOR N CARPORT NOTICE
TOTAL SQ.FT.
DECK GARAGE SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. TOTAL SO.FT. CONDITIONING.
NO.OF STORIES BASEMENT Y OR N THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
LIVING AREA BASEMENT COMMENCED WITHIN 180 SAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SQ.FT. J30 TOTAL SQ.FT. CHECKONE ABANDONED FOR A PERIODOF 180 DAYS AT ANYTIME AFTERWORK ISCOMMENCED.
PERMANENT FIREPLACE ATTACHED
SEASONAL SHORELINE DETACHED
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 LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQ IREMENTS FOR 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 ONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
O AINING APPROVAL FROM THE BUILDING DEPARTMENT, t l a APPROVAL FROM THE BUILDING DEPARTMENT.
OW NE EDATE !?7 /lJ XBY DATE
FOR OFFICE USE ONLY
DEPARTMENT APPROVED DEPARTMENT APPROVED BUILDING VALUATION ✓
YES NO YES NO
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
/'
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATESURCHARGE
APPLICATION ACCEPTED BY I PLANS CHEC B� APPROVED FOR ISSUANCE PERMIT VALIDATION
�� i�+-�' BY OV`/m CASH CK MO TOTAL
PLOT PLAN
ADDRESS A),E , 3 a ' JD AV LC J,OA16 5 ,PL , Ae
I,CA/K PERMIT NO f o
z �
LEGAL
DESCRIPTION <L/l, :7 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 At"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.
' I \ INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
f
1 r0 /G I
r T °
Z /
I
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.
N AME(S1 OF WNERISI OF SITE Q STRUCTURE(S) (PRINT) SIGNATUPE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
CHRISTMASTOWN PRINTING