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03/15/99 MON 11:26 FAX 3604277798 MASON COUNTY BLD 3 (ti1002
' FORM MUST BE COMPLETED 1N INK
PERMIT NO.! ' -OIZ(
PLEASE PRESS HARD MASON COUNTY
DEMOLITION PERMIT APPLICATION 7-7-111)
426 W.Cedar/P.O.Box 166,Shelton,WA 88684
Shelton(3601427-8670 Belfair 360 275-4487 Elma(360)482-5269 ?cattle/206)464-6968
APPLICANT INFORMATION CONTRACTOR iNFOR ATION
Owner v 777{ Contractor Name lie)
Mailing Addre 1.56_,c1 G.fr •erlam« 5IV. Mailing Address_
City &set•^f State t Zip Code t?9-6,4. ,.`{ City ~-State er Ph.( Zip ,Code '
Phone ,y17-,q777Other Ph.(9 ) Ph-( )
Lien/Title Holder — Contractor Reg.# _
Address Expiration_ / /
PARCEL INFORMA ION-1 di!it Tax Pal
I � el No. .�� ! � I o�9 Fire District
Legal Description 1, a . 4 / rsc ` • - , 9
Site Address(include stre name and cit - _. _ �� ,,,
Directions to site: s 7 /" ioo.�l �
is your property within 200' of the following: Body of Water(Name) At),-,,-, Cv,r---P 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 fut re development prior to demolition; since removal of an existing structure could
affect future building locations. _. .
I
How will the debris be disposed of? P.,. , . 1111,0-- •
/is ' -
What is the use of the building being demolished?_�.wi w► er- i0�t ce, " `` tt'
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
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 Regiistration 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
Iwork will be done in confo Once therewith. NO changes shall be made without aaridmad hout firsto doneeiin c approval mance therewith. No changes shall
I first obtaining a
X_Dg____> to Date 3/� -9F X Date l
Provide a plot pi n indicating location of improvement and -tructure to be demolished.
1-(9 -SS OK V ' P& *�'c"(km,e,
r /
Y1
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_1 r . , r4.L,,_ 5k) 1 _____________,. A)
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L rnea f1CCIf+1 A i I IOC DC /f P.Irii TVIC Of11AIT
03/15/99 MON 11:26 FAX 360427779$ MASON COUNTY BLD 3 Zo02
FORM MUST BE COMPLETED IN INK PERMIT NO. 'VI'0l 2�/
PLEASE PRESS HARD 'MASON COUNTY ,,1
DEMOL TION PERMIT APPLICATION
416 W.Cedar/P.O.Box 188,Shelton,WA 98584
Shelton(360)42T-967p� Beifair(360)275-4487 Elma(36)482-5269 Seattle(208)464.8968
APPLICANT INFORMATION CONTRACTOR INFOR ATION r
`
owner JnN�(I _SPnF� Contractor Name °t °�
5 ��?7� _ >.-, . 1-1 °; '�t���S��'�
Mailing Addre ' G/c.,•e,-60,- Mailing Address
City &s State ' Zip C e 9 /`94 City State Zip Code '
Phone 4//7-d.7770ther Ph.(9) , ) Ph.( ) Other Ph.( )
Lieft/Ttle Holder Contractor Reg.#_._= .Z.:.
Address Expiration_ hz
PARCEL INFORMA ION-1 di it Tax Parcel No. .tea i o 95 Fire District I
Legal Description k 4 i «€ '° ,y _, h
Site Address(inClude stre name and cit . J A —� „�
Directions to site s f5 Aloe, 0-"' A. i"',—( '� "' r0 £ec es•`c f--.
is your property within 200' of the following: Body of Water(Name) /4-,;r,-L Saltwater '-
Lake River/Creek Pond 1, 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 Mure building locations. 1
How will the debris be disposed of? �`�i' 0.-- ' r's
What is the use of the building being demolished? si A^mfrt `s" Vii`4 '' 7."- Ct.Z',"'
-- ...g.
"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 owners behalf,represents that the
I information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
I 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
I 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 confo nce therewith. No changes II be made without and all work shall be done in conformance therewith. No changes shall
first obtaining a / be made without first obtaining approval.
X 1--- Date$1 -5T X,.........--.-- Date
Provide a plot pl 'n indicating location of improvement and -tructure to be demolished.
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