HomeMy WebLinkAboutMIS94-0398 Pre-Inspection - MIS Application - 6/14/1994 MIS
L5i MASON COUNTY
RE-INSPECTION APPLICATION
J U N 14 04 426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670
$25.00 Fee Required prior to inspection
PLEASE PRINT O
#1 Owner (� Phone#
Site Address C' City
Mail Address
City d St
Applicant S Phone# �}'
Applicant Address
City l/ /d!S/ St Zip zeCS-2ng
#2 Parcel No.a2 Y'5-
Legal Description $ .i/�Pis 3 2,:V& 1cT�
#3 Purpose of Pre-Inspection
s:z�
#4 Use of building �',�Ue�`T1f�G
#5 Indicate by circling the applicable source if any water is on or adjacent to subject property:
altwat lake creek stream marsh river pond wetland seasonal runoff other
Directions to Site:
��� �1���_�-r Of l�SllOi✓ ems' dFf� ' ��.l�,F ��
- c9 !! lf)G
Show following on the site plan below: Lot Dimensions, Existing Structures, Structure Setbacks, Water Lines, Septic Systems,
Flood Zones, Wells, Shorelines, Easements, Name of Flanking & Fronting Streets. Indicate directional by N, S, E, W, etc.
lJ tV
Applicant Signature - Date
FOR OFFICIAL USE ONLY: Accepted by: s =' Date:_ y.
Receipt No. Ref br ed To
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
FPro
posal Proposal
roved Denied
Planning:
i
Building:
Fire Marshal:
Special Conditions