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MIS
MASON COUNTY
MISCELLANEOUS PERMIT PPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 584. 427-9670
PLEASE PRINT
#1 Owner ,� ,= Al .�! . �SC'c� Phone# - � Fire District#
Site Address Z . City
Mail Address
City St ?L1 Zip jf�5—
Applicant Phone#
Applicant Address
City St Zip
Directions to Site: Ak
#2 Parcel No. /
Legal Description
#3 Indicate by circling the applicable source if any water is on or adjacent t
the property site:
saltwater lake river creek stream pond wetland seasonal runo marsh other
#4 Project Start Date Project Con ipletion Date %o -- —
#5 Use of Buildiing r? a 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 CONTRA ORS AFFIDAVIT
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 F THE ORDINANCE REQUIREMENTS REGULAT-
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE ORK 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 FIRST OBTAIN ING APPROVAL FROM THE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNERC C?._ � X BY
DATE & DATE