HomeMy WebLinkAboutBLD2393 Mobile Home - BLD Application - 6/16/1978 BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
DATE ISSUED / 7dp
PERMIT NO. q
OWNER i�ME MAIL ADDRESS CITY&STATE ZIP PHONE
DIRECTIONS
TO JOB SITE
LEGAL II�/` E /�-�MxL/C 'f 2)'v �_ O / (❑ SEE ATTACHED SHEET)
DESCR. I,1,f/
NAME AIL ADDRESS l>✓l CI STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING
a
Class of work: "EW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
Valuation of work: $ / ?J a-�Q . PLAN CHECK FEE PERMIT FEE ®
SPECIAL CONDITIONS:J
APPLICATION ACCEPTED BY PLANS CHECK BY AP ROVED FOR ISSUA�CE Type of y Occupancy Division
Const. /9 /r Group
Size of
Bldg. No. of
(Total) Sq. Ft�4 X 4(e Stories Occ. Load
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.
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
of the Mason County Ordinance requirements for SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
which this permit is issued and that all work done will
be in conformane therewit THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED
1 //'� �p w/ IS NOT COMMENCED WITHIN DAYS, OR CONSTRUCTION O WORK IS
vy SUSPENDED OR ABANDONED FOR OR A PERIOD OFF 120 DAYS AT ANY TIME AFTER
O r Date. WORK IS COMMENCED.
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O.
PLOT PLAN
ADDRESS PERMIT NO.
LEGAL
DESCRIPTION LOT BLK ADDITION
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 Al"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'
00
01
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.
NAMES) OF OWNER(S) OF SITE & STRUCTURE(S) (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
GHEITON PMNTIN'�
I