HomeMy WebLinkAboutMIS99-0628 Cancelled ReRoof - MIS Application - 7/11/2024 FORM MUST BE COMPLETED IN INK qq
PLEASE PRESS HARD
PERMIT NO.: MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INF RMATION CONTRACTOR INFORMATION
Owner lt. tractor Name r e
Mailing Address -0 � Wiling Ad Jess
City��P, ,;.�, State Zip Code 990.39 City ���t� n State� Zip Code
Phone(U.2SS ) 4J -20k6 Other Ph.( Ph.(_ qJ6-7o 7 Other Ph.(
Lien/Title Holder Contractor Reg. # 1Lgn,SPll
Address Expiration _/ f l�-00
PARCEL INFOR ION-12 di Tax Pa cel / / Fire District
Legal Description i T L_ .
Site Address(include street name and city 1 �. A• Q
Directions to site: C
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 .rP
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-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 mad ithout rst obtaini approval. c�r
)( Date X 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
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee Other
UFC Plan Review Fee Other
Violation Fee Pre-Paid at Submittal ( )
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
bate by Gas Piping date by
Foundation Walls date by Set Up
date by INSULATION date by
BGISLAB Insulation Floors Finai
date by date by date by
FRAMING Walls FIRE DEPT.date by date by date by
PLUMBING Attic OTHER
Groundwork date by
date by WALLBOARD NAILING
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date by
date by
Water Line ! date
FINAL INSPECTION by
date by � •-C(i date by
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