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FORM MUST BE COMPLETED IN INK PERMIT NO.:
PLEASE PRESS HARD
MASON COUNTY
DEMOLITION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 2T5�467 Elma 360 482-5269 Seattle 206 64-6968
APPLIC IFORIVI I p FPh.
NTRACTOR INFORMATION
Owner Yl L- i ��1G/ G ntractor Name
Maili Ad ess D e iling Address
City 4' } State W Zip Code y State Zip Code
Phone �g 3�Other Ph.(� (_� Other Ph.(_�
Lien/Title Holder CLtyl// Contractor Reg.#
Address Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. 1 Z- / / Fire District
i
Legal Description
Site Address(include treet na an ity G r
Directions to it : Pe4
y Saltwater
Is yo property within 200' of the following: ody of Wa er(Name)
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs If your project is located adjacent to or within an area that is listed above, it is advisable to contact the Dept.
of Community Development regarding future development prior to demolition; since removal of an existing structure could
affect future building locations.
Ho)*yrjl�h bris b Is ed of?
?
What is the use of the building being demolished.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMM ED WITHIN 180 DAYS OR IF
EN
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER T �6lOR S COOMMENs that the
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owne die ,
f Mason County access to the above described properly And�sxtruc«1frefevi (and
information provided is accurate and grants employees o
inspection of this project. Acknowledgment of such is by signature below: /NJAY 1 LJ
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT �fy yat�11r1 Currgn ray 0§red as a
contractor in the State of Washington an thE�+�vYa orthe
the Contractor Registration law RCW 18.27 and am aware of the ordinance requirements regulating the wq Qr,vvl7�Fh h �j r>�t i5.i,�sl'ed
ordinance requir ents for which this permit is issued and that all work q g g "�r]4h hit bfi ges3h!
will bed c n rmance therewit . No changes shall be made without bedmade without all work shallfi first obtaining approval.
ere i
first ain g ap r I
X Dat Date
Provide a plot plan indicating location of improvements and structure to be demolished.
C' -ei
�4 }7rE�G�✓a` �] ryi �pmll�
FOR OFFICIAL USE BEYOND THIS POINT
E Accepted by
-Date-Submittal Amount Due Receipt No.
CONDITION COD
DEPARTMENTAL REVIEW APPROVED DENIED
4
Building Department
Occ Gr Type of Const. A^
Planning Department of I
Fire Marshal
FEES ERMIT ASSISTANCE CENTER
Building Permit Fee Other
Violation Fee Other
Ste Inspection Pre-Paid at Submittal ( )
TOTALFEES
\ \0
PERMIT NO
MASON COUNTY 7
DEMOLITION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Skelton,WA 98584
Shelton 340 427-9670 Belfair 360 275-4467 Elora-360 482-5269 Seattle 206 464-6968
APPLIC 1pitFORIVIPI CONTRACTOR INFORMATION
M Contractor Name
Owner rl4..- ¢
Maili Ad ess 0 Mailing Address
City a� State Zip Code City State Zip'Code
` Phone Other Ph.( ) Ph.( ) Other Ph.(_�
Contractor Re #
Lien/Title Holder � g
Address Expiration
PARCEL INFORMATION Fire Distri
-12 digit Taz Parcel No. / /
c
i Legal Description �
Site Address(includ street narr►e an ity
. 1 f
Di ections site: ✓� t' 9
�s f h r
Is yo property within 200' of the following:43ody of Water(Name) rl' Saltwater_
I Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
j Bluffs If your project is located adjacent to or within an area that is listed above, it is advisable to contact the Dept.
of Community Development regarding future development prior to demolition;since removal of an existing structure could
i affect future building locations.
I `
Hopi Il � bris b Isp sed of?
C G�'Gf
k7
�
fJ
What is the use of the building being demolished?
is
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 owners behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above describ 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 AFFID xIT-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 faashington and that I am aware of the .�
! ordinance re uirefnents for which this permit is issued and that all work ordinance requirements egplating the work for which this permit is issued
...
VWII be conformance tjren3wit Np'shangeshail be.made without and all Work shall be done in conformance therewith..:.No.changes shall
first in gap rgval be made without first obtaining approval a.
, .
jX Date Date
l
R Provide a plot plan indicating location of improvements and structure to be demolished.
�r Fo
i •
_ FOW OFFICIAL USE-BEYOND-T #3OINT -_
Accepted by Date Submittal Amount Due Receipt No.
CONDITION CODES
DEPARTMENTAL REVIEW JAPPR(JVED DENIED
Building Department Qq
I Occ GrD Type of Const.
Planning Department Cy —
Fire Marshal
FEES
t Building Permit Fee Other
i
t Other
Violation Fee
Site Inspection Pre-Paid at Submittal ( )
TOTALFEES
PERMIT NO.:
MASON COUNTY °
DEMOLITION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 3i60 427-9670 Belfair 360 276-4467 Elme 360 482-5269 Seattle 206 464-6968
APPLIC Ipdf0R�A 1 N 1100 CONTRACTOR INFORMATION .
Owner r/ Ett j G�/ - Contractor Name
Maili A d ess 4) Mailing Address
City 14re rStateWA ZipCode7YJ35 City State Zip`Code
Phone Other Ph.(� Ph.r�� Other Ph.(�
Lien/Title Holder C+t Contractor Reg.#
Address Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. 3 1- / / Fire District
Legal Description
Site Address(includn VA
street narft an ity � '
e tionsto It ✓;a y!1 C
z w., _.. , . . MY
rt-
4! i
Is yo property within 200' of the following:43ody of Water(Name) Saltwater��
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs If your project is located adjacent to or within an area that is listed above, it is advisable to contact the Dept.
of Community Development regarding future development prior to demolition; since removal of an existing structure could
affect future building locations.
How will the ebris b Isp sed of?
What is the use of the building being demolished? �l� �
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 owneOs-behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above describ d 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 AJoashington
IT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in,the Stat and that I am aware of theordinance requirements for which this permit is issued and that all work ordinance reg0iremeating the work for+which.this permit is issued ,M
wAl,be confot*mance.therewit�l_ No changestshall be,made without -and all work shall be done in conformance therewith. No changes shall
first I-i g ap roval f r be made without frst obtaining ap oval.
X
D0,
ate 5' X Date
Provide a plot plan indicating location of improvements and structure to be demolished.
16��Fo
G'►�`+/K � �
C5
FOR'=OFFICIAL`S USE-BEYOND.-T:1413 POW,
Accepted by Date Submittal Amount Due Receipt No.
[Violation
EPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
epartmentC, ,T e of Const.Department halFEES
Permit Fee Other
FeeOther
ection Pre-Paid at Submittal ( )
TOTAL FEES
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