HomeMy WebLinkAboutMIS99-0586 Cancelled ReRoof - MIS Permit / Conditions - 9/13/1999 to ..4 C_ C
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FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD
PERMIT NO.: MIS�zz—
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
APPLICANTANFORMATION CONTRACTOR INFORMATION
Owner (,-P,0/K�l 9/- /y01 W—A TG 4w Contractor Name Sc/1c
Mailin Ad ess ��45'�-/ 5 ^ s/ 3 Mailing Address
City State.[ Zip Code geS—x City State Zip Code
Phone Other Ph. I Ph.( Other Ph.0
Lien/Title Holder ,�,� s' 6,�c. Aar.-s Contractor Reg.#
Address Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. / / Fire District
Legal Description
Site Address(include street name and city
Directions to site:
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� o41g�4
/too Dn ��,a�t j?p tJ
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 AFFIDAVIT-1 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-1 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 a roval. be made without first obtaining approval.
Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due �� Receipt No.
DEPART TAL REVIEW APPROVED DENIED CONDITION CODES
Building Department rav upon I
4
Occ GrpType of Const. PX t
Planning Department ���j. ar* �Ttkh,bn_ +
Environmental Health Department _1
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee O Site Inspection
Plan Review Fee Other 2�47 AT oO
UFC Plan Review Fee Other
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES �'