HomeMy WebLinkAboutCOM2012-00154 Demo Old House - COM Permit / Conditions - 12/21/2012 _
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FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD PERMIT NO.: �_—
MASON COUNTY DOIS2I
DEMOLITION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 4825269 Seattle 206 464-6968
APPLICANT I�FIORMAa I �N -I L CONTRACTOR INFQRMATIO C
Owner 1 1/4m I"L I ✓11( X s1[3���ST tCz ,�I a Contractor Name l��✓l D �i01� Gp
Mailing Add sr�7 Mailing AddrFess 6
City State W4 Zip Code a S�NI _ City 60 State Zip Code 17 S�,Q
Phone(3alI2 6AZkoZ,7 Other Ph.( Ph.( c�-66 1 5 hjDther Ph.(
Lien/Title Holder Contractor Reg. #
Address Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. G 2029_ 3 /_56 / Gk7p0 Fire District
Legal Description
Site Address(include street name and city
Directions to site: 2 mi Ct,ik arP n&H,9c4P
Is your property within 200' of the following: Body of Water(Name) Saltwater
Lake River/Creek_ 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.
How will the debris be disposed of? O{
What is the use of the building being demolished?
NOTICE: THIS PERMIT BECOMES NULL 8,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-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 / X Date
Provide a plot plan indicating location of improvements and structure to be demolished.
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FOR OFFICIAL USE BEYOND THIS POINT