HomeMy WebLinkAboutBLD11695 Dock - BLD Application - 11/6/1981 _ BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATE ISSUED
PERMIT NO.
NAME /• MAIL ADDRESS �CITY&STATE ZIP PHONE
OWNER
DIRECTIONS
TO JOB SITE rj�a p d
LEGAL j� SEE ATTACHED SHEET)
DESCR. / _s4fhit �� H� X&t 4 f7 f O L ,so?
NA(ME MAIL ADDRESS CITY&STATE LICENSE NO. PHONE
CONTRACTOR . �— —
USE OF
BUILDING e e-
Class of work: EW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describgg work: (�
hoc r1TA ree Sec4hS D Q D y a E? T-1411 6a)y loh arjo ty y ,les
i, L'on�rnitc,/ S�- DM +2 Qce�5 0 WAlIc 4 �OC-S fo�eJ '-d-ee�' � vo,
Valuation of work: $ PLAN CHECK FEE PERMIT F 3 F,-
SPECIAL CONDITIONS: Vc/
BEDROOMS I DECKS __ CARPORT ❑ NOTICE
BATHROOMS TOTAL SQ. FT. _T GARAGE [I
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT [] OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE U DETACHED ❑
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR-
CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS
SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER
I certify that I am a currently registered contractor in WORK IS COMMENCED.
the State of Washington and I the
aware of the FOR OFFICE USE ONLY
ordinance requirements regulating the work for which
the permit is issued and all work done will be in
conformance therewith. PERMANENT 1 1 SHORELINES ❑
SEASONAL ❑ FLOODPLAIN 1.1
Firm E.D. NO. S.E.P.A. L
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT.
PUBLIC WORKS
I certify that I am exempt from the requirements of the FIRE MARSHAL
contract or registration law RCW 18.27, and am aware BUILDING DEPT.
of the Mason County ordinance requirements for
which this permit is issued and that ail work done will ROAD ACCESS
be ' onformance therewith. MOTOR VEHICLE PERMIT
_ LICATION ACCEPTED BY PLANS CHECK BY APPROV R ISSUANCE
Ownef - Date.�
It/Y , kb�r
P AN CHECK VALIDATION CK. M.O. CASH iOERMIT VALIDATION CK. M.O. CASH
i
PLOT PLAN
f�
ADDRESS Gy� /'l PERMIT NO. ° o
s z o
LEGAL
DESCRIPTION LOT BLK ADDITIO►a 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.
0 INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
NJ 'Ilk
1
a p -5- ,
I/We certify that the proposed const uction 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 S1TE 6 STRUCTURE(S) (PRINT) SIGNATURE OF OWNER( OR AU HORIZ D REPRE� T TIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
OHCLTON PRINTING