HomeMy WebLinkAboutMIS96-00001 BULKHEAD - MIS Application - 12/28/1995 MASON COUNTY >1
MISCELLANEOUS PERMIT APPLI pO - 4
426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-967O
PLEASE PRINT
#1 OWner o/eELj1 g Phone# qS%-34'1S7 `,Fire District
Site Address . 11IL ('_LyY I City
Mail Address Ai iS
City ',-1. St __ Zip_________________
Applicant t7721c7 Phone# 95 .3/S7
Applicant Address „/ 22 Al
City P7jl—' St 1c Zip
Directions to Site: - /e /'1 dç
Lo- -- / (?// ' z,J/ 7L77s
#2..,\ Parcel No. //9O - -
\ ' Legal Description L7 Z" / ffr7S76 /J i7T
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site:
( twat lake river creek stream pond wetland seasonal runoff marsh other
#4 Project Start Date A1/ ?I* /9 ' .' Project Completion Date ,4 i '// /92L
#5 Use of Buildiing Describe proposed construction
d_ % 2 7/1l1r
*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 CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON-
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
WITHOUTFIRSTOBTAININGAPPROVALFROMTHEBUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT. /
X OWNER X BY xeY >
DATE DATE / - 8-
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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
I FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning G✓ A 1 CLi T LU"—1 p/TIO�LS APP COND APP HOLD
of—ZZ
Building
Fire Marshal
Other
Special Conditions Fees
Permit Fee $ 7
Plan Check
Other
Other
State Building Fee • -'
` TOTAL DUE $