HomeMy WebLinkAboutBLD N/A Demo SFR - BLD Application - 4/28/1999 FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD PERMIT NO.:
MASON COUNTY
DEMOLITION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Contractor Name
Mail Address ' ( Mailing Address
Cityipg))kok)b State QfZ Zip Code City State Zip Code
Phone(- 1 ) 6_ty,�- 3Jther Ph.( Ph.( Other Ph.0
Lien/Title Holder Contractor Reg. #
Address i Expiration
PARCEL INFORMATION-12 digit Tax Parcel No. 42304 / q01 / (�;VO,20 Fire District
Legal Description
Site Address(include street name and city tiE
Directions to site:
Is your property within 200' of the following: Body of Water (Name) c.ct r C r r e K Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs If your project is located adjacent to or within an area that is listed above, it is advisable to contact the Dept.
of Community Development regarding future development prior to demolition; since removal of an existing structure could
affect future building locations.
How will the debris be disposed of? 6�fr /L _
What is the use of the building being demolished? Too Q0S7Z JI&PAIlf
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
11>� e done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
ll JfirsLtaining ap al. be made without first obtaining approval.
X ) - 1 4 y X Date
Provide a plot pla indicating location of improvements and structure to be demolished.
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E a 'FOR OFFICIAL USE B OND THIS POINT
7'm 0 e4l' Gre�eFC-
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department �-
Occ Grp Type of Const.
Planning Department
Fire Marshal
FEES
Building Permit Fee yZ co Other
Violation Fee Other
Site Inspection Pre-Paid at Submittal ( )
TOTAL FEE S
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION
Case No.
Namel ! ^IgUrV PARCEL NUMBER/;?--Jp9 —4/2 ?ll1Date
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
11 Names of Fronting Streets Septic System
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line.
adjacent property line-> , h I E-adjacent property line
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adjacent property line4 I I E-adjacent property line
SAMPLE SITE PLAN
adja�nt property line-� adjacent property line
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SFAS r✓A" I _�PTSL _,-
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adjacent property lined i a'• \i Fadjacent ro ert line
TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.)
SAMPLE TOPOGRAPHY PROFILE
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d;btar,Cr- ro
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disrar,ca.
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ggnatuiu ree ( Date