HomeMy WebLinkAboutMIS96-0904 Foundation - MIS Application - 12/19/1996 Z Yl:�-Vrf\-VM�kSON
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MISCELLANEOUS PERMIT APPLICATION yam, &
426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670
PLEASE PRINT
#1 r .D o Phone#C34 o, —6 C� Fire District
ite Address E S O Vti ' P► City �� ' WA
Mail Address ER f� Z� W R r ��-t^ v�-
City " ` "� St IN Zip S`� Z
Applicant C O l Phone# 6 ° 1
Applicant Address 5A-,,. . S
City St Zip
Directions to Site:
al Description Vim, 2- r S r'2 z� j ,
#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 runoff marsh other
#4 Project Start Date Gi l.. 4,17 Project Completion Date 'F'-e l ,I 7
#5 Use of Buildiing S A Ili Describe proposed constru n
f cti S .
'Fyry OrR��I
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'Depending upon the type of permit,a floor plan and plot plan may be required. O C , 9
'This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT CONTRACTORS AF H SERVt
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 HANGES SHALL BE MADE WITHOUT FIRST
WITHOUT FIRSTOBTAINING APPROVAL FROM THE BUILD- OBTAINI PP OVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER X BY
DATE DATE
Show following on the site plan
Lot Dimensions Flood Zones '
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements Indicate directional b
Septic Systems Name of Fronting Street y
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
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Building
Fire Marshal
Other
Special Conditions Fees
Permit Fee $
Plan Check
Other
Other
State Building Fee
TOTAL DUE $
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