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BUILDING PERMIT APPLICATION
MASON COUNTY
Y
DEPARTMENT of GENERAL SERVICES
i . . BOX 186 SHELTON, WASHINGTON 98584
427-9670 DATE ISSUED'
SUED
PERMIT NO
NAME MAIL DRESS CI Y&STATE ZIP PHONE
DIRECTIONS
TO JCS SITE IJak L, iL ri Jct± t ±nLoi
PARCEL LEfaA
NE 3111 GovJjDESCRJ - ' �
NAME MAIL ADDRESS DIVASTATE LICENSEN 7, ZIP PHONE
COCONTRACTOR
USE OF
BUILDING
CL SSCM NEW �ADDITJON ALTERATION REPAIR MOVE JMOVE
WORK
ESCSIBE
WORK ...
BEDROOMS DECKS JCARPORT .�,..w_ NOTICE
SEPARATE PERMITS ARE I E DU RI FOR PLUMBING, HEATING, VENTILATING OR AIR
BATHROOMS.. TOTAL SO.FT CJARAOE _. ...,.. _ __ CON 7ITIONIN ,
NO OF STORIES BASEMENT wm _.. . ATTACHED_ „..„._ THIS PERMIT BECOMES NULL AND OP F WORK OR CONSTRUCTION AUTHORIZED IS NOT
COMMENCED WITHIN 180 BAYS, DR IF CONSTRUCTION OR WORK IS SUSPENDED OR
TOTAL SO ET. . .w FIREPLACE M_ _ DETACHED ARAN NED FOR A PEMOD OF 18CI DAYE AT ANY TIME AFTER WORK ISCOMM NCED.
PERMANENT SHORELINE
SEASONAL µ
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY );HAT AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTOR I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF
R GISTRAIJON LAW ROW 18.21,AND AM AWARE OF THE MA S tN CO HOC OR MNANCE WASHINGTON AN I AM AWARE DI THE ORDINANCE REQUIREMENTS REGULATING THE
REQUIRE NTS FOR WHICH THIS PERMIT'IS ISSUED AND THAT ALL WORK DONE VIL!SE WORK FOR W $CH THE PERMIT IS ISSUED AND ALL WORK NE IA+ILL AT IN
IN CONFIRMANCE THEREWITH. NO CHANGES SHALL SE MADE WITHOUT FIRST CONFORMANCE THEREWITH,NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING
O TAINT C:APPROVAL FROM THE BUILDING DEPARTMENT,. APPROVAL FROM THE BUILDING DEPARTMENT,..
XOER E S't: .: DATE
DEPARTMENT ENT AYESPPROV NO DEPARTMENT YES APPROVED O BUILDING VALUATION
HEALTH PUBLIC ORS FEE
PLANNING 4 FIRE BUILDING a PERMIT
D; .T. SU#1 DIRT PLAN CHECK
SPECIAL CONDITIONS BUILDING GROUP PRE-INSPECTION
SHORELINE
WOODSTOVE
PLUMBING
MECHANICAL
STATE BUILDING FEE
STATE SURCHARGE
AP AT ON ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION TOTAL
SAY CASH Olt_ MIS