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Home My WebLink AboutBLD2005-00618 DEMO Final - BLD Permit / Conditions - 8/18/2005 FORM MUST BE COMPLETED IN INK C�005 —000 PLEASE PRESS HARD PERMIT NO.: MASON COUNTY DEMOLITION PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 276-4467 Elma 360 2-5269 Seattle 206 464-6968 APPLICANT INFORMAT N CONTRACTOR INFORMATION Owner Contractor Name Mailin Address ` Mailing Address City State LA& Zip ode City State Zip Code Phone(25S ) -We Other Ph. Ph.0 Other Ph.( LienlTitle Holder Contractor Reg.# Address Expiration PARCEL INFORMATION-12 digit ax Parcel No. / Fire District Legal Description 7 Site Address(include et nam an city Directions to site: Is your property within 20C f the following: Pofiv of Water(Name) Ale L4 IJ&V Saltwater Lake River/Creek Pond Wetland Seasonal Run Stream Slopes or e 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 debris be disposed of? 10, What is the use of the building being demolished? 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. l 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: °s OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-1 certify that fg t�y lst r d as a the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that 1 am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work f� yc 9t�h�' issued j' will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance thh.lNshall first approval. be made without first obtaining approval. 3 E L F I R OFFICE X Date — — X Date Provide a plot plan indicating location of improvements and structure to be demolished. s� S � 3v2 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 Fire Marshal FEES Building Permit Fee Other Violation Fee Other Site Inspection Pre-Paid at Submittal ( ) TOTAL FEES PERMIT NO.:r MASON COUNTY DEMOLITION 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 APPLICANT INFORMATION. ! i CONTRACTOR INFORMATION Owner J #h ;«:.. % , h� Contractor Name i'e-0 Mailing Address j f r, Mailing Address City r ,°t. , State Zip code City State Zip Code Phone(; Other Ph.( Other Ph.( � Lien/Title Holder ; 4 i, . � .CL= >.i Contractor Reg.# Address Expiration PARCEL INFORMATION-12 digit Tax Parcel No. %.'.J f; �f �:.�') /'�/) ';/ ;i' Fire District Legal Description 4 Site Address(include street'name and city N Directions to site: { Is your property within 200' of the following:*Body of Water(Name) Saltwater - Lake River/Creek Pond Wetland Seasonal Runtff 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 debris be disposed of? What is the use of the building being demolished? 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: [['((��rta CC� OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify thaRE 1� IW"ed as a the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the works t ' is issued will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance tfi� 1c ' shall first obtaining approval. be made without first obtaining approval. 3ELFAIR OFFICE X ' / Date X Date N Provide a plot plan indicating location of improvements and structure to be demolished. 2. _ •S 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. 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