HomeMy WebLinkAboutMIS93-0228 Storage - MIS Application - 5/27/1993r
MIS_
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
PLEASE PRINT V, X ON
A �(C) = _ —
#1 Owner lv.ce/ / Phone # �e - 4/0`7 3 Fire District# —r
Site Address JL) l 2(, / L�, CA red City,
Mail Address Cc,
City St Zip
Applicant Phone #
Applicant Address
City St Zip
Directions to Site: (� ,� /I� IZ�;) S � c�� ,( ,� j 1 eA 1,
Jell o-� CA ,b,ks .
#2 Parcel No. n
Legal Description 5 Se 1'>" %(o '�o� �..s� �3 �o�i<l, �/«.�r c L.�i
#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 S' ;Z 7- c73 Project Completion Date
#5 Use of Buildiing j?4rSide, , c c Describe proposed 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 APPROVALFROMTHE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER,' �"� X BY
DATE - j— c1 I DATE
L - -
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
I
V
40 /+Crej
Q�
i
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
Permit Fee $
�T�N Ptt� t-6 �U (I sT" Plan Check
Other
Other
State Building Fee
TOTAL DUE $