HomeMy WebLinkAboutBLD11683 Addition - BLD Application - 11/4/1981 r'r
BUILDING PERMIT APPLICATION
MASON COUNTY
P.O. Box 186 Shelton, Washington 98584
426-5593
DATE ISSUED
PERMIT NO.
OWNER NAME MAIL ADDRESS CITY&STATE ZIP PHONE
Cam. 32 96
DIRECTIONS
TO JOB SITE
LEGAL ( SEE ATTACHED SHEET)
DESCR.
NAME MA ADDRESS CITY&STATE LICENSE NO. PHONE
CONTRACTOR
USE OF
BUILDING
Class of work: ❑ NEW ADDITIbN ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
Valuation of work: $ PLAN CHECK FEE h7 PERMIT F 5�
�17L S-
SPECIAL CONDITIO .
BEDROOMS I DECKS CARPORT ❑ / NOTICE
BATHROOMS . TOTAL SQ. FT. GARAGEK 5 D
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES BASEMENT ❑ ATTACHED K OR AIR CONDITIONING.
TOTAL SQ. FT. FIREPLACE C] 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 FORA PERIOD OF 180 DAYS AT ANYTIME 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 J SHORELINES ❑
SEASONAL ( , FLOODPLAIN
Firm E.D. NO. S.E.P.A. Ll
By Special Approvals IN OUT YES APPROVED NO
Lic. No. ate /� -5�'fsr ZONING
CANNING 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
of the Mason County ordinance requirements for BUILDING DEPT.
which this permit is issued and that all work done will ROAD ACCESS
be in conformance therewith. MOTOR VEHICLE PERMIT
LIGATION ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE
Owner Date .
P CHECK VALIDATION CK. M.O. CASH V VIDERMIT VALIDATION C . M.O. CASH
PLOT PLAN
ADDRESS ,L::-� �rl PERMIT NO. o
,
1 0
A O
O
LEGAL
DESCRIPTION LOT J BILK 1 ADDITION JyX1.
SITE AREA Sq.Ft. AREA OF SITE OCCUPIED BY BUILDINGS Sq. Ft. C
1
INSTRUCTIONS TO APPLICANTAll
C 'V
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 ARID SEWER SERVICE ELEVATION. SHOW LOCATION OF WATER, SEWER, GAS AND ELECTRICAL o
SERVICE LINES.SHOW LOCATION OF SURVEY PINS.SPECIFY THE USE OF EACH BUILDING AND MAJOR POR-
TION THEREOF.
C"� INDICATE NORTH IN CIRCLE GRAPH SQUARES ARE 5' X 5' OR 1"=20'
i
�s t
I/We certify that the proposed construction will conform to the dimensions and uses shown above andl�that no changes will be made without
first obtaining approval.
NAMES) OF OWNER(8) OF SITE 6 STRUCTURE(S) (PRINT) SIGNµ URE OWNER(3) OR A THORI2 ED REPR 3ENTATIVE
DO NOT WRITE BELOW TyHIS LINE
APPROVED
DISTRICT AS NOTED S� DATE
GHELTON PRINTING