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MIS I
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584.427-9670
PLEASE PRINT
#1 Owner &VJ Phone# Fire District# ��
Site Address City
Mail Address
City St Zip
Applicant Phone# �
Applicant Ad ress C)(D
City St U 1p Zip �
Directions to Site:
#2 Parcel No.
Legal Description
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site:
saltwater lake river creek stream pond wetland seasonal runoff marsh other
tq
#4 Project Start Date +O/h/q LJ Project Completion Date
#5 Use of Buildiing Describe proposed construction
*Depending upon the type of permit,a floor plan and plot plan may be required.
*This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT NMI
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED COW
MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT-
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND
IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE-
FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUT FIRSTOBTAINING APPROVAL FROM THE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER X gyl
DATE PATIE
Show following on the site plan
Lot'Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR -4XXXX
� NLY7 dy DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building
Fire Marshal
Other
Special Conditions Fees 00
Permit Fee
Plan Check
Other
Other
State Building Fee LA
TOTAL DUE $
�u .
-------------
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
Mason County Bldg.111426 W.cedar
P.O.Box 186 Shelton.washtngton 9WU
(36M 427-9670
BUILDING PARKS&RECREATION FAIR/CONVENTION CENTER ADMINISTRATION
TO:f;er jol�e
u•6• ayoi7a $f. �-
87 -
�-�.r�, CUi4 98�5a 8`
RE: Permit Number # /n/s 9 y_
I
To Whom It May Concern;
During a recent review of our files, it was determined that your permit
may-meet one of the following criteria:
1 . Permit is expired and needs to be renewed or have a final Inspection
2. Due to the type of your permit and scope of work it is possible that
the work has been completed and it needs to be inspected to close
the permit
or
3. The permit is ready to expire and needs to be inspected or an
extension needs to be requested.
j Permits are valid for 180 days from the date of issue to the inspection
date and remain'valid for 180 days between each required inspection.
If our records are inaccurate and you have had a final inspection, please
send a copy of the signed off permit to this office so that we can update our
cards. If you have not had a final inspection and your permit is expired or will
expire within 30 days, please contact this office for a final inspection, update
inspection or extension prior to _&r/ D /96 to avoid renewal fees.
All permits which are expired or due to expire within the next 30 days will
become null and void if contact is not made with our office.
If you should have any questions regarding permit validity or the purpose
of this notification, please contact the building department for clarification.
Sincerely,
Building Depart ent