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Home My WebLink AboutChange of Use - MIS Application - 11/2/1998 FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT NO.: MIS MASON COUNTY MISCELLANEOUS PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 27.9670 Belfair 360 275.4467 Elma 360 2-5269 Seattle 206 64-6968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner S Contractor Name Mailing Address QQ Mailing Address City�� ,Q sn_ State_� -Zip Code City State Zip Code Phonekia )z7S-GdrQ�bther Ph.(Mo)O -7/q 2. Ph.(_� Other Ph.(___� Lien/Title Holder Contractor Reg.# Address Expiration / / PARCEL INFORMATION-12 digit Tax Parcel No. Zz2. / Q_/ Lr Fire District_ Legal Description Site Address(include street name and city 7!7 1?O A E. it/A:�!f f f �i4l R Directions to site: JAf1-d%LChz'r>o,,v mo26 .6 h' & Q Will timber be cut and sold in parcel preparation? (Yes/No) Is your property within 200' of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Adder Alt Repair Other Use of Building Describe proposed construction lzh a lope o-C if.4's o' SHORELINE PROJECTS New Replacement Repair Expansion Bulkhead Material (concrete, rock, wood, etc.) Length Height A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT. 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: OWNER AFFIDAVIT4 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-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 Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall first obtaining approval. be made without first obtaining approval. Dat Date 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 Environmental Health Department Public Works Department Fire Marshal k Valuation $ FEES Building Permit Fee Site Inspection Plan Review Fee Other UFC Plan Review Fee Other Violation Fee Pre-Paid at Submittal ( ) TOTAL FEES FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT NO.: MIS MASON COUNTY MISCELLANEOUS PERMIT APPLICATION 426 W.CedarM,O.Box 186,Sheltpn,WA 98584 Shelton 360 27-9670 Belfair 360 275-4467 Elma 360 2-5269 Seattle 206 464-6968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner X AW 7,V 04 SgAr c Contractor Name Mailing Address 'fit:,. uo rS :Z Mailing Address City Z r 11 .14 State .Zip Code 0zlinvX City State Zip Code Phone�i �Z S=Gk c Other Ph. g f[ h Other Ph.(� Lien/Title Holder Contractor Reg. # i Address Expiration PARCEL INFORMATION-12 digit Tax Parcel No. /Zrg z 5&V Fire District_ Legal Description L-Arc j�r !_i�t-/ Zr e C t �� /� , A f 1� I Site Address include street name and city ��►�„__t��t, AL&tif' —Xi r ed2ia Directions to site: i Will timber be cut and sold in parcel preparation? (Yes/No) Is your property within 200' of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add—_Alt Repair Other Use of Building Describe proposed construction. , SHORELINE PROJECTS New Replacement Repair Expansion Bulkhead Material (concrete, rock, wood, etc.) Length Height A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT. w 1 { NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF I 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 a 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 AFFIDAVIT-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 Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall first obtaining approval. be made without first obtaining approval. Date f/-L—q X Date s FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. x DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Occ Grp, Type of Const. Planning Department f 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