HomeMy WebLinkAboutBLD2004-01911 Pre-Inspection - BLD Application - 12/20/2004 MASON COUNTY
PRE-INSPECTION APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 360-427-9670
$58.00 Fee Required prior to Inspection
PLEASE PRINT
#1. Owner o9V1<- cc+.e P 177?� Daytime Phone # -206, -7/3
Site Address a--v Gr City
Mail Address o ! ,e! cjcje ,s--i9
City /,?y St Zip 1790 y/
Applicant
Applicant Address /� 8w s-�9
City St Zip ;790y/
#2. Parcel No. `�5a
Legal Description
#3. Purpose of Pre-Inspection -
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#4. Use of Building t n C-"7V
#5. Indicate by checking the applicable source if any water is on or adjacent to subject property:
❑ Saltwater ❑ Lake ❑ Stream ❑ Marsh ❑ River ❑ Pond ❑ Wetland ❑ Seasonal Runoff❑ Other
Directions to Site: 104yL, 3 )`zl /��9-f df✓G�c /2 o�-a �x /rr� �id ,���dv lS�
��f�(/�6r, 0/✓ L'Q/I NGnZ D/C /P I3UG✓ a✓Z yJl�SO�t/ Ls4-Kcr j2�
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 & Frontage Streets. Indicate
directional by N, S, E W, etc.
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Applicant Sign itUre- �'� Date
38
FOR OFFICIAL USE ONLY: Accepted by: t
Receipt No.kl 1 efer. ed T.
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY Prosal Proposal
Appropoved Denied
Planning:
Building:
Fire Marshal:
Special Conditions