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HomeMy WebLinkAboutUntitled (1866) 415 N 6�"STREET, SHELTON WA 98584 MASON COUNTY SHELTON: 360-427-9670, EXT. 400 1P11"-7 COMMUNITY SERVICES BELFAIR: 360-275-4467, EXT. 400 ELMA: 360-482-5269, EXT. 400 Building,Planning,Environmental Health,Community Health FAX: 360-427-7798 i APPLICATION FOR EXTENSION 1!)11COMEVItl Amount Paid: AV Receipt Number:, D3 b `D JUL 2 8 2023 10 Instructions: Complete Parts 1 and 2. Submit application with extension permit fee. Make check payable to Mason County Treasurer. Staff will review your application and determine if the extension can be approved. If approved, the permit may be extended for up to one additional year from the original expiration date. Extensions must be applied for prior to original expiration date. Multiple extensions on a single permit will not be approved (one per design/permit). PART 1: APPLICANT AND PARCEL INFORMATION � Name of Applicant: DAut 0 1P�'I`I?R SJ� Cf�Phone: 0 S94- SG tS Mailing Address of Applicant: 846 S OAt u So N 'c ' Il City: It Ara State: T k Zip: '4 co 2S 12-digit Tax Parcel Number: 12103 C " ti clad 30 Site Address: S21 C C-,00"4\0(44 �111.� • S14E,VT0 NI 1 \Js}F 9 g Sg T Permit Number: SWG 241.20. Ob° SWGt Z.620 ©O 13 PART 2: EXPLAIN WHY YOU NEED AN EXTENSION. WE AM %haA ITU t FbQ. c . LAST 'pti.Lo;N 4 .nn.; k 415 Qe Wiz. ewe_ Gves c V‘u jn (A tou P;No OvR GcrN 2. CPcTiWoT - . $r;L. a Z.. 202 . Qjc4os - -c .oft Ta - s I 6S A C.. t'+•I s1 45"%•/ PART 3: HEALTH DEPARTMENT DETERMINATION (staff use only) 16NExtension Denied 0 Extension Approved New Expiration Date: Comments: �„/-r � Q I r C u ] { 2 S - 2 tX ' rl �1,r / Environmental Health Specialist Signature: ( .�1�A This form may be scanned and available for ub - 'ew on the Mason County Web site. /v \ ©fl G �x'1 e � �1 Y poi; C Revised: 12/13/2019 %u apply e