HomeMy WebLinkAboutBLD15738 Mobile Home - BLD Application - 6/18/1984 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATE ISSUED �7 7`
PERMIT NO. / � / 5
OWNER NAME MAIL ADDRESS CI STATE ZIP PHONE
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DIRECTIONS _f ` 1f
TO JOB SITE Su„d '1 �aj k�cs!' 0,1 10 54� Wl�/�2 �/TOo
LEGAL Q (❑ SEE ATTACHED SHEET)
DESCR. 1�Z�'j3 C_o✓e dl'✓ V D� go
CONTRACTOR NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
USE OF
BUILDING INo e /9l09 5 Gc�r.aS !' ke-A Z'I'X SS' Z o,c_
Class of work: lX NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR K MOVE ❑ REMOV
Describe work:
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co li w-c( ow ef'S G a- hliS}1' e' I,•r '�s ow1�
V �ors /n 0 pov �' . �- act /6,0
Valuation of work: $ PLAN CHECK FEE PERMIT FEE
SPECIAL CONDITIONS: �oun �1 •O/� • I.✓1'/I r 01 �L O �7 izf%
C ter` ' as� o�.r� >'`��.l fh e � �r-�- Si� 4 ro✓�1 i S
+� �Co K.f P/-1,7 k, 0 C M;e O C / S
BEDROOMS I DECKS CARPORT D NOTICE
BATHROOMS 2— I TOTAL SO. FT. GARAGE [A
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT [! ATTACHED f_1. OR AIR CONDITIONING.
TOTAL SO. FT.J-3-10 I FIREPLACE X DETACHED ❑
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR-
CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER
I certify that I am a currently registered contractor in WORK IS COMMENCED.
the State ofWashington and I aware of the F O OFFICE USE ONLY
ordinance requirements
the regulating the work for which
t e permit is issued and all work done will be in ft
onformance therewith. PERMANENT X1 SHORELINES
IVA-
SEASONAL ❑ FLOODPLAIN L
Firm
E.D. NO. S.E.P.A. [I
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT. ` 3 m,.
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 onformance therewith. MOTOR VEHICLE PERMIT
�` �r LIC:AYTN ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
Owner Date TN^L t By r
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS d le,i 'CS co,, e- PERMIT NO. f o— _ z a
11 D
.7 O
LEGAL Div ,
) �{
DESCRIPTION D r/_ LOT �7C BLK ADDITION
SITE AREA —Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS Sq. Ft. `sue
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"ID 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.
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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.
NAME(S) OF OWNERS) OF SITE ! STRUCTURE(S) (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
6NELTON PRINTING