HomeMy WebLinkAboutBLD24390 Mobile Home - BLD Application - 9/7/1989 BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
427-9670 DATE ISSUED
PERMIT NO.<Z::R ,
OWNER NAME MAILADDRESS tJ CITY&STATE ZIP PHONE
7 !/i R Tp T' 14,25t
DIRECTIONS /SIsJj/ 3/l/atr# TO$ LD / muCy 300 �,r/oe7A? SAoR.rR�
TO JOB SITE '� v t
uy A5.4-, OW .06#7- XA tiD s/,qr, //owXe clacs7 A)007W 0-;4lo7 /-/ / TAf/A/y4 Ro
PARCEL q LEGAL n/'� �OA'7�'/ /Vo. e7' C zz d/vv
NUMBER ad oC DESCR. �TNBJp : T p"I"Wt To 4 'a
Tdt./A�37f+/7�otaZ.tloRll`I
NAME MAIL ADDRESS rITY 8 TA E LICENSE NO. P PHONE
CONTRACTOR
USE OF
BUILDING
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK ✓
DESCRIBE
WORK
BEDROOMS DECKS__,,,,,-- CARPORT NOTICE
y SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
J BATHROOMS � TOTA lffGARAGE CONDITIONING.
NO.OF STORIES BASEMENT ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SQ.FT. X10 FIREPLACE DETACHED ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PERMANENT _ SHORELINE
SEASONAL
JGI
RS AFFIDAVIT CONTRACTORS AFFIDAVIT
FY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
ATION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
EMENTS 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
FORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
NG APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
E --0ATE X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT APPROVED DEPARTMENT APPROVED BUILDING VALUATION
YES NO YES NO i
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK ,
SPECIAL CONDITIONS BUILDING GROUP R— PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE D
STATE SURCHARGE
APPLICATION ACCEPTED BY CK BY APPROVEQ FOR ISSUANCE PERMIT VALIDATION TOTAL
14W �� CASH CK MO 1 .26 ��
PLOT PLAN
ADDRESS PERMIT NO. s o
= s
n s
s o
0
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 AND 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'
Z n
ye
ro
�I
I/We certify that the proposed construction will oonform to the dlmensidns and uses shown above and that no changes will be ithout
first obtaining approval. -
NAME(S) OF OWNER(S) OF SITE S STRUCTURE(S) (PRINT) tIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE