HomeMy WebLinkAboutPre-Inspection - SPI Application - 1/9/1991 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584 J�J-7 f
427-9670 D TE ISSUED /
PERMIT
OWNER
NAME MAII,ADDRESS CITY&STATE ZIP PHONE
DIRECTIONS /) .
TO JOB SITE PARCEL AL1
NUMBER Gj—� —(�( DSCR. IV E
NAME MAIL ADDRESS CITY 8 STATE LICENSE NO, ZIP PHONE
CONTRACTOR
USE OF
BUILDING
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK ✓
DESCRIBE lo
WORK Z
BEDROOMS DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. GARAGE CONDITIONING.
NO.OF STORI ES BASEMENT ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 SAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SQ.FT. FIREPLACE DETACHED ABANDONED FOR A PERIOD OF180 DAYS AT ANY TIME AFTER WORK ISCOMMENCED.
PERMANENT SHORELINE
SEASONAL
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGISTRATI LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIREM T 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 CONF ANCE THEREWITH. CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH,NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAININ APPROVALj}ROM TH ILD DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
OWNER DATE / C�I X BY_ 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
STATE SURCHARGE
APPLICATION ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION
TOTAL
BY CASH CK MO