HomeMy WebLinkAboutMIS94-0862 Conditional Installation - MIS Permit / Conditions - 10/17/1994 MASON COUNTY
Mason County Bldg. 111 426 W. Cedar
P.O. Box 186 Shelton, Washington 98584
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MASON COUNTY
Mason County Bldg. III 426 W, Cedar
' P.O. Box 186 Shelton, Washington 98584
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MASON COUNTY
�-- Mason County Bldg. III 426 W. Cedar
P.O. Box 186 Shelton, Washington 98584
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MIS_ = �
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670 PLEASE PRINT G (-,(g
#1 Owner Q t{ Phone# Fire District#__
Site Address PJ. c_ 2 City h a . ('
Mail Address
City St c, Zip `� C6 Z_
Applicant Phone#
Applicant Address
City St Zip
Directions to Site: � CS a A_� 44 w
c CA'C-C y!:�
#2 Parcel No.
Legal Description
#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 I O/ ILI % `{ Project Completion Date 1 0 �S
#5 Use of BuildiingcU 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 COW
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 CH NGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUTFIRSTO I ING VAL FROM OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTM N J MENT.
X OW ER f X BY
DATE G DATE
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 irectional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
M
y
FOR OFFICIAL USE ONLY:Accepted by .�' "' '� Date;_^ � �
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building L .�
Fire Marshal
Other
Special Conditions — Fees
— Permit Fee $ ��
Plan Check
— Other.
— Other
— State Building Fee
— TOTAL DUE $