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permit No. 0169 No. Floors Sq Ftg 480
Owner BENNETT, Howard Tel Date 9-5-89
Address P 0 Box 5227 Bear Cr_. Sta Belfair Zip
Contractor None
Address Zip
Legal Description Tr 58 Survey 11117 10-23-2
Direction to project site 1690 Blacksmith Lk Dr NW
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1
BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584 n
426-5593 DATE ISSUED
PERMIT NO.
OWNER NAME -7-� MAILADDRESS CITY TAT ZIP PHONE
ff,
DIRECTIONS ` !
TO JOB SITE b. (� i t AOR . ?I ? r
-
PARCEL LEGAL �. ����
NUMBER `� � I Q -7V_
CONTRACTOR DESCR.
NAME MAIL ADDRESS TY&STATE LICENSE NO. ZIP - PHONE
USE OF
BUILDING �®� G
CLASS OF NEW ADDITION ALTERATION REPAIR MOVE REMOVE
WORK
DESCRIBE
WORK
BEDROOMS DECKS CARPORT NOTICE
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS TOTAL SQ.FT. GARAGE 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. W C' FIREPLACE DETACHED_ ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER WORK IS COMMENCED.
PERMANENT SHORELINE
SEASONAL
OWNERSAFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
REGISTRATION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIREMENTS 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 CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBTAINI APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X O#R DATE `-� X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT APPROVED DEPARTMENT APPROVED BUILDING VALUATION l ' t",
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
APPLICAT N ACCEPTED BY I PLANS CHE RY APPROVED FOR lq�IUANCE PERMIT VALIDATION
GL/ ,�10'„,6' BY �� z' CASH CK MO TOTAL / /,
r
PLOT PLAN
n
,
13 5% � � I `�ti r�N) c� ? Xri R � 'zIT NO.ADDRESS i
j = s
�n s
LEGAL��3/0-
DESCRIPTION LOT 1) Q BLK ADDITION t3
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' ,
Ye i
. V
xq 41
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e 1v Ae T RIB
I/We certify that the proposed construction will conform to the dimensions and uses shown above and that no changes will be made without
first obtaining approval.
W14 AP Gl //r J
NAME(a) OF OWNER(S) OF SITE STRUCTURE(:) (PRINT) IGNATURE OF OWNERIS) OR AUT RIZEO REP ESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE