HomeMy WebLinkAboutMIS99-0291 Cancelled ReRoof - MIS Application - 5/28/1999 ST BE COMPLETED IN INK
SE PkESS HARD PERMIT NO MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLIC T INFORMATION / CONTRACTOR INFORMATION
Owner J=I `- J `l Contractor Name
Mailin Address ) Mailing Address
City N State Zip Code City State Zip Code
Phone( Other Ph.(_____) I Ph.( Other Ph.( )
Lien/Titl Ider Contractor Reg. #
Addres Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. / / / Fire District
Legal Description ti z
Site Address(include street name an city
Directions to site:
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe proposed construction
SHORELINE PROJECTS New Replacement Repair Expansion
Bulkhead Material (concrete, rock, wood, etc.) Length Height
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washingion and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first obtaining approval. be made without first obtainig approval.
X Date X y� �✓ Date
--*
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department
Occ Grp Type of Const.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee Other
UFC Plan Review Fee Other �_ l�O O C.
Violation Fee Pre-Paid a Submittal ( )
1>>'
TOT AL FEE S
>....
i
REGISTERED AS PROVIDED BY LAW AS
CONST CONT SPECIALTY
REGIST. # EXP. DATE
CCCDCH MRBRO**146C8 09/21/1999
EFFECTIVE DATE 02/28/1986
M R B ROOFING
1027 S W SPRUCE RD
PORT ORCHARD WA 98366
Signature
1, Issued by DEPARTMENT OF LABOR AND INDUSTRIES