HomeMy WebLinkAboutMIS - Propane for BLD96-0328 - MIS Application - 11/14/1996 1
MASON COUNTY MIS
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
PLEASE PRINT
#1 Owner rno-rsb4. rr y Phone # 14�-4 woQ Fire District#
Site Address l d iO 1 ti vY. �t� S City LLn
Mail Address go o 3�
City `J L'0- I � St zip
Applicant 'E\'JC'^S � wc'� Cbr�St- r Jyk Phone # L{a 40 -gcd(oa
Applicant Address Po IS, oo jo
City c5Lj f-vr' St wft Zip q( s-
Directions to Site:
H-W�-r ( 6 U D�S� If�I �.Q Qnlo�rvoLs- Inn i i rmbe/ �1c.Q15 c...J�
2_ c�n `�' ►�i��^-� C�a 1ti3O `�•e �t� l l �O Vli-ns ' LUc,,tD S
#2 Parcel No. 3 act 3S - -7 S - 1y l �
Legal Description 1►' 3 Of 5�yrf P # 1 y l�I
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site: J
saltwater lake river creek stream pond wetland seasonal runoff marsh other
#4 Project Start Date \q—gcp Project Completion Date
I(L— C 8�t�gto
#5 Use of Buildiing Describe pro osed 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 CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY 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- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER X BY � t CL4 I
DATE DATE
I
Show following on the site plan .�
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements directional by
Indicate dir
Septic Systems Name of Fronting Street I N, S, it W etc
Proposed Improvements Name of Flanking Street
PLOT PLAN AREA
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building
Fire Marshal
Other
Special Conditions Fees TZ'ar�
Permit Fee Dom , $
Plan Check
Other
Other
State Building Fee
TOTAL DUE $ —