HomeMy WebLinkAboutBLD4095 Mobile Home - BLD Application - 12/8/1976 BUILDING PERMIT APPLICA TIO
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
DATE ISSUED
PERMIT NO.
OWNER -� NAME MAIL ADDRESS CITY TATE ZIP PHONE
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DIRECTIONS
TO JOB SITE
LEGAL / (❑SEE ATTACHED SHEET)
DESCR. ) l�ti v� r` L
CONTRACTOR c' .� ���d r'�� / f3 c;
NAME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
USE OF
BUILDING � �
Class of work: ❑ ADDITION 7 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
Valuation of work: $ PLAN CHECK FEE PERMIT FEE
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SPECIAL CONDITIONS:
ApkAjATION ACCEPTE BY PLANS CHECK BY APPR E FOR IS ANCE Type of Occupancy Division
BY Const. Group j
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Size of Bldg. No. of Max.
(Total) Sq. Ft. Stories Occ. Load �G
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. O
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 SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
of the Mason County ordinance requirements for VENTILATING OR AIR CONDITIONING.
which this permit is issued and that all work done will
be ' conformance therewith. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED
IS NOT COMMENCED WITHIN 120 DAYS, OR IF CONSTRUCTION OR WORK IS
2 Q� 7 SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT ANY TIME AFTER
Owner Date VV ` WORK IS COMMENCED.
P AN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS PERMIT NO. f o
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M D
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LEGAL a
DESCRIPTION LOT BILK 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 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 POR-
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 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
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