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10 It% MIS
MASON COUNTY
MISCELLA14EOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 9 584 • 427-9670
PLEASE PRINT
#1 , Owner '�gy .�c, wreTw/�/,c1c� Phone # 2(0 (v �2. Fire District#_14 _
Site Address — % M /ti 4 ' ZQ2 City
Mail Address ,49- ov
City e,cJ St Zip 9 'r
Applicant Phone#
Applicant Address
City St Zip
Directions to Site:
#2 Parcel No.
Legal Description I le/wG MO A)[V
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site:
saltwater lake river creek stream pond wetland seasonal runo f marsh other
#4 Project Start Date D V4 1 Project Con Oletion Date
#5 Use of Buildiing �2— De cribe proposed construction
'Depending upon the type of permit,a floor plan and plot plan may be required.
'This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT CONTRAC ORS AFFIDAVIT
f
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIF THAT I AM A CURRENTLY REGISTERED CON-
MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT-
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND
IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE-
FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUT FIRSTOBTAINING APPROVAL FROMTHE BUILD- OBTAINI APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER' X BY
DATE -7 �- 9 DATE
Sh
ow ow following on the site plan b
Lot Dimensions Flood Zones " M
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicatedirectional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
-__ -
/4-60! S �e.-ro.v 5PP-i v&s 2v, %ram M�, �r-o 14wy l o/
FOR OFFICIAL USE ONLY:Accepted
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building 1 Y1 C o , - VCR o'e
Fire Marshal
Other
Special Conditions Fees _
Permit Fee
Plan Check
Other
Other
State Building Fee C4 5
TOTAL DUE $ 2, Z6 0