HomeMy WebLinkAboutBLD1705 Mobile Home - BLD Application - 4/11/1975 BUILDING PERMIT APPLICATION
MASON COUNTY
P. O. Box 400 Shelton, Washinqton 98584
DATE Ai!_/ I--Zs = , m
PERMIT NO.
Applicant to complete numbered spaces only. - N
JOB ADDR ESS
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LEGAL (❑SEE ATTACHED SHEET)
OWNE��'' MAIL ADDRESS d IIP PHONE
2 t1c?j7 N 1u o'-o
CONTRACTOR MAIL ADDRESS PHONE LICENSE NO.
3
ARCHITECT OR DESIGNER MAIL ADDRESS PHONE LICENSE NO,
4
ENGINEER MAIL ADDRESS PHONE LICENSE NO. I�
5 I`
LENDER MAIL ADDRESS BRANCH
6
USE OF BUILDING
7
8 Class of work: ❑ NEW ❑ADDITION ❑ALTERATION ❑ REPAIR OVE ❑ REMOVE
9 Describe work: IPL `C-- iL Lp-
4
10 Change of use from
Change of use to
11 Valuation of work: $ C%00.� �?
PLAN CHECK FEE PERMIT FEE ,2&, DO
SPECIAL CONDITIONS:
Type of Occupancy
Const. Group Nf•/// { Division
Size of Bldg. t No.of Max.
(Total) Sq. Ft.S _ Stories Occ. Load
Fire Use Fire Sprinklers
APPLICATION ACCEPTED BY. PLANS CHECKED BY APPROVED FOR ISSUANCE BY. Zone Zone Required ❑YeS ❑No
•J� ,/1 OFFSTREET PARKING SPACES:
Dwelling Units Covered Uncovered
NOTICE Special Approvals Required Received Not Required
ZONINC.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING,
HEATING, VENTILATING OR AIR CONDITIONING. HEALTH DEPT. s�
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION FIRE DEPT.
AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS, OR IF CONSTRUC- OTHER (Soecify)
TION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF
120 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
I hereby certify that I have read and examined this application and
know the same to be true and correct. All provisions of laws and
ordinances governing this type of work will be complied with whether
specified herein or not. The granting of a permit does not presume to
give authority to violate or cancel the provisions of any other state or
local law regulating construction or the performance of construction.
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)
SIG T RE OF OWNER IF OWNER BUILDER DATE)
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION cK. M.O. CASH
'=H.LT O,V PGiIVTI,�:G CO
PLOT PLAN
ADDRESS PERMIT NO. Z 7 o 0
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In D
LEGAL
DESCRIPTION LOT / '� r? ! j. BLK ADDITION
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SITE AREA Sq. Ft. AREA OF SITE OCCUPIED BY BUILDINGS r'Z __Sq. Ft.
INSTRUCTIONS TO APPLICANT
THIS FORM NEED NOT BE USED WHEN PLOT PLANS DRAWN TO SC,:,LE 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 & STRUCTURE(S) (PRINT) S1GNArrURE OF OWNERS) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
GHELTON I'RInTI•.,