HomeMy WebLinkAboutMIS98-00493 Cancelled Fence - MIS Application - 9/10/1998 FORM MUST BE COMPLETED IN INK �� '
3 PLEASE PRESS HARD PERMIT NO.: MIS �
MASON COUNTY
V 40
_104 MISCELLANEOUS PERMIT APPLICATION MYW
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275.4467 Elma 360 482-5269 Seattle 206 64-6968
APPLICANrINFORMATION CONTRACTOR INFORMATION
Own r 1 ` ', Contractor Name -i�lMC.
Mail g Address n v� � Mailing Address
City �f .ace State UJP Zip Code 2S 1�S' City State Zip Code
Phone( , () ) J 1. 1. -/.(,—Other Ph. -/,,() Ph.( Other Ph.(
Lien/Title Holder Contractor Reg.#
Address Expiration / 711.11
RAJ�CEL INFORMATION-12 digit Tax Parcel No. / / C'C) C? Fire Distri t
Legal Description ! of SL"jq c F < C 0 ?' LAJ
Site Address(include street na a and city Stj/ 4J I . ""
Directions to site: ' 1901E O 4� c 41 ,c-ft: 1t k,r, C
Will timber be cut and sold in parcel preparation? (Yes/
Is your property within 200' of the following: Body of Wa e) VO Saltwater
Lake River/Creek Pond Wetl Seasonal Runoff Str m Slopes or
Bluffs
TYPE OF JOB New_Add Alt R Other Use of Buil g i :TR
Describe proposed construction ,
X % , ; J., / �Z. L--
SHORELINE PROJECT New placement Repair Expansion
Bulkhead Material (concre , rock, ood, Length Height
iiiiiiiiiiiiiiii0v
A FLOOR N AND PLOT AN AY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT.
NOTICE: THIS PERMIT BEC ES NULL&V I ORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS S ENDED O B ONED FOR A PERIOD OF 180 DAYS, ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATIOROF RK IS M NS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is ate a is a loyees of Mason County access to the above described property and structures for review and
inspection of this project' Ac wledgment such is by signature below:
OWNER AFFIDAVIT-I certify at I am exempt m the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law CW 18.27 a am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which t ' er ' Issued and that all work ordinance requirements regulating the work for which this permit is issued
will be done in conformance therewith. No ch ges shall be made without and all work shall be done in conformance therewith. No changes shall
first obtaining approva, be made without first obtaining approval.
r
X 1 aC/ Date > /(1- f J X ::is �� e"` Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted Date 1 Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department
Occ Grp Type of Const.
Planning Department
Cl
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee Other
UFC Plan Review Fee Other
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES