HomeMy WebLinkAboutMIS97-0724 Conditional Installation - MIS Application - 10/21/1997 MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670 �lie? O
PLEASE PRINT
#1 Owner k.'b+r, r L",Svfu Phone # 3'6o Z75—Z 1lO Fire District#_ Z _
Site Address 44$5 c-�lcl ge/4',airZ /—/&Uy City
Mail Address Sv4 wt --f
City � �_ ►�� 2 St wk4- Zip q 6's—8
Applicant S� �_ Phone #
Applicant Address
City St Zip
Directions to Site: 1_4'("V /11c erk 10,1 tS GL4#tt''<
C�bc�vT I�y1i/rS ova GAT Sr�t �l
t
#2 Parcel No. a2_a 7� - __2 --
Legal Description -IT, Mzg
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site:
saltwater lake rive re stream pond wetland seasonal runoff marsh other
#4 Project Start Date Project Completion Date �5�/�
#5 Use of Buildiing Describe proposed construction
OCT 21 �ee�
'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. PERMIT ASSISTANCE CENTER
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 FIRST OBTAINING APPROVAL FROMTHE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER X BY
DATE �� Z� f DATE
J
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICI L USE ONLY
Planning '►�L t� l " APP COND APP HOLD
Building 3
kff aAm�z Ive 6f
Fire Marshal
Other
Special Conditions Fees
Permit Fee $
Plan Check
Other
Other
State Building Fee
TOTAL DUE $