HomeMy WebLinkAboutBLD10241 Mobile Home - BLD Application - 3/19/1981 BUILDING PERMIT APPLICATION
MASON COUNTY
SU _ �3v P.O. Box 186 Shelton, Washington 98584
426-5593
1 ! r /` DATE ISSUED
EW 3�U2� — S� v3�Q�j PERMIT NO.
OWNER M SS CI 8 STATE ZIP PHONE
14
DIRECTIONS
TO JOB SITE
LEGAL �J I l- / (❑SEE ATfACHED SHEET)
DESCR
A AIL DD ESS CITY 8 STAT LICENSE NO. PHONE
CONTRACTOR c
91
USE OF /
BUILDING
1 4_r�
Class of work: NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
Describe work:
o -
Valuati n f work: $ PLAN CHECK FEE PERMIT FEE
a"
SPECIAL CONDITIONS:
BEDROOMS I DECKS CARPORT❑ NOTICE
BATHROOMS TOTAL So. T. GARAGE ❑
ATTACHED ❑ SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING
NO. OF STORIES SE T ❑ OR AIR CONDITIONING.
TOTAL SO. FT 'a ACE ❑ I 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 ❑ SHORELINES ❑
SEASONAL ❑ FLOODPLAIN ❑
Firm
E.D. NO. S.E.P.A. ❑
By Special Approvals IN OUT YES APPROVED NO
Lic. No. Date ZONING
PLANNING DEPT.
OWNERS AFFIDAVIT HEALTH DEPT. /G)�3
PUBLIC WORKS
I certify that I am exempt from the requirements of the FIRE MARSHAL
ntract 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 all work done will ROAD ACCESS
be in conformance therewith. MOTOR VEHICLE PERMIT
/0 ! PP ICATION ACCEPTED BY PLANS CHECK BY APPRO�yED FOR ISSUANCE
Owner A ate. � BY itS407z,,-,
PLAW 6HECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH
PLOT PLAN
ADDRESS PERMIT NO. /-Aa"7 z, f o
i o
A D
D OO
LEGAL
DESCRIPTION LOT BLK ADDITION 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 P"ID 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'
I/We certify that the pro ion will conform to the di nsi sand uses shown above and that no changes will be made without
first obtaining approval.
NAME(S) OF OWNER(S) OF SITE k STRUCTUREM (PRINT) SIGNATURE OF OWNER(S) OR AUTHORIZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
SHELTON PRINTIN3