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Date By Date By FINAL INSPECTION Water Line Date 2 t 1/bj— By Date By ... _ Date By N O O � V1 O [�J O O O w 0 w 01/05/2005 15:23 FAX 360 427 7798 MASON CO PERMIT CTR Z 001 FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT N1-- i6i MASON COUNTY DEMOLITION PERMIT APPLICATION 426 W.CedarlP.O.Box 186,Shehon,WA 98584 Shelton 360 279670 BeNair 360 275-467 Elma 60 82.5289 Seattle 206 4.6968 APPLICA INFORM TION NTRACTOI INFO MATION Owner Contractor Name fJ Mailing Address ailing Address City S ate Zip e < City 1 tate f1eL Zip Code Phone UOther Ph.(�� ) Ph. - Other Ph.(� Lien itle Holder gmbA 19D S Contractor Reg.# Address�- -� Expirations/ / PARCEL INFOR O 12 digit Tax cel No. .���a�50 11 i/ Fire District - Legal Description C Site Address(include street,name a d ity 7 C Directio s to site: 4va Is your property within 200'of the Poll ng:Body of Water(Name) Saltwater Lake River/Creek_1,::L 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 will t e d tins b disp ed of? What is the use of the building being demolished? NOTICE: THIS PERMIT BECOMES NULL d VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED wmmN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 190 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 1 am exempt from the requirements of CONTRACTORS AFFIDAVIT-1 certity,that 1 am currently registered as a the Contractor Registration Law RCW 1827 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 1willbedonaincAnformancetherewith. No changes shag be made without and all work shall be done in conf No changes shall fast obtalning I. be made ut first obtairurg I..� X / Date r �✓ X Provide a plot plan indicating location of improvements and structure to be demolished. FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDmON CODES Budding Department75 1 Occ G T of Const. �4 r 6 Plannng Department a C/G�'f " oo 3-/G Fire Marshal FEES Building Permit Fee Other Violation Fee Other Site Inspection Pre-Pant at Submittal ( ) TOTALFEES | � -T� � � \ � n] �� 7| ' | laj_-L---'-----' \J | i I y S f t OP GN Z^_ D i y. n -a 1 y 1 dW 01/05/2005 .15:24 FAX 360 427 7798 MASON CO PERMIT CTR 2002 Notification of Demolition Permit It is unlawful for any person to cause or allow the demolition(or major renovation)of any structure unless all asbestos- containing materials have been removed from the area to be demolished. Work shall not commence on an asbestos project or demolition unless the owner or operator has obtained written approval from ORCAA. A written application for a demolition shall include a certification that there is no known asbestos-containing material remaining in the area of the structure. Project Site Address: 7fP J'� I'4/ County: / City: /'I/ State: /,I JfI Starting Date: / ALL Completion Date: �p *(Them is a 10 working day advance notification period from receipt of permit application) Property Owner:CALin fiW'r 'ter' Telephone:--fbe- 5IS-, f�,W Fax: .-3/0, fi fS- Mailing Address: t` -4,7�P /4 i&6 City: l&M State:Ltd Zip: Demolition Contractor: &ILGE SA41�e State License#: Mailing Address: eg -72 IZ92 City: State:Gt)fA- Zip: qg 3�3 Contact P rson: Telephone:c2— /Y->-> — ! � Fax: YES NO Demolition by Wrecking or Dismantling? ($25.00 fee)check# Training Fire Demolition? (If yes,attach fire department request for training fire) 4 Renovation,Alteration,Remodeling,Maintenance,or other Constructidn? Asbestos found or suspected* *An ORCAA"Notice of Intent to Remove or Encapsulate Asbestos"form and appropriate fee must be submitted prior to any asbestos removal work. Asbestos removal projects involving demolition must be preformed by a Certified Asbestos Contractor and all friable or potentially friable asbestos must be removed before any demolition begins. Refer to ORCAA Regulation 1 Article 14 for additional requirements that may apply. Asbestos Survey Completed by AHERA,Certified Inspector Certification# I This approved permit must Enclose$25 Certification of the Asbestos Survey must be available at the job site Processing Fee accompany this form I 2940 B Limited Lane NW,Olympia,Washington 98502 360-586-1044 * 80OA22-5623 * fax 360-491-6308 homepage:www.orcaa arg * email: in orcaa Rev.07/11/02 i I k- 1 w �4 ze •d s��s�st��es all kdat WON dw i Nam wd sz: ze t ooz—s T—33a y 4 c� N � • Yfi 201d 8b£8£Sti609T all vadwtla OWINU A Wd SZ: Z0 v00Z-ST-33a .w l�L f � I g �a ! w � tr0 'd 8tr�8 Str60ST all tJQHWHa OWINVA Wd 9Z: ZO tr60Z-ST-83Q