HomeMy WebLinkAboutBLD18962 Move Mobile Home - BLD Application - 7/14/1986 I
BUILDING PERMIT APPLICATION
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
P.O. BOX 186 SHELTON, WASHINGTON 98584
426-5593 DATE ISSUED/7"' -4f
PERMIT NO.fCi 1 G
OWNER AME MAIL ADDRESS CITY&STATE ZIP E
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DIRECTIONS
TO JOB SITE a,�� v
' LEGAL
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DESCR.
NAME MAIL ADDRESS CITY&STATE LICENSE NO. ZIP PHONE
CONTRACTOR
USE OF
BUILDING
CLASS OF NEW ADDITI ALTERATION REPAIR MOVE (� REMOVE
WORK
DESCRIBE
WORK "71(�J ,/ i �` v. u ' /• �/
OF
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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 SO.FT. A& FIREPLACE DETACHED ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED.
PERMANENT SHORELINE
SEASONAL
OWNERS AFF AVIT CONTRACTORS AFFIDAVIT
I CVFT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
RELAW RCW 18,27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REGULATING THE
RE 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
INNCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
OBPER
�ROVALL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT.
X OW /0" / DATE X BY DATE
FOR OFFICE USE ONLY
DEPARTMENT YES APPROVEDJO DEPARTMENT YES DEPARTMENT
BUILDING VALUATION
HEALTH PUBLIC WORKS FEE
PLANNING FIRE BUILDING PERMIT
D.O.T. BUILDING PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
PLANNING
116
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATESURCHARGE
APPLICATION ACCEPTED BY PLANS CHECK BY AP OVE R ISSUANCE PERMIT VALIDATION
L TOTAL
�• ..l�.r'e�z � CASH CK MO
PLOT PLAN
ADDRESS �C �j�. /�¢/,�Qd ' � j �/L ,yyl¢�1i�y:•��c�/7 PERMIT NO. a
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LEGAL ' N
DESCRIPTIONS LOT '��J BLK ADDITION ,
SITE AREA_Id"X /";)4y 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 Al"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.
INDICATE NORTH IN CIRCLE_ GRAPH SQUARES ARE 5' X 5' OR 1"=20'
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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.
NAME(S) OF OWNERS) OF SICFE d STRUCTU (S) (PRINT) 3IGNATURE OF OWNER(S) OR AU IZED REPRESENTATIVE
DO NOT WRITE BELOW THIS LINE
APPROVED
DISTRICT AS NOTED DATE
CHRISTMASTOWN PRINTING