HomeMy WebLinkAboutMIS99-0389 ReRoof - MIS Application - 7/7/1999 PERMIT NO.: MIS 0119 J C)
MASON COUNTY
MISCELLANEOUS 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 LA IV t r,,- -J it s Contractor Name
Mailing_Addr8's J2.8 . 1 f, Mailing Address
City �e 1 jc',12 State ', Zip Code c14s`SU City Zip Code
me '15 Phone ) k '-DiUother Ph.( ) Ph.( 1 fie 4ZL.j )
Lien/Title Holder Contractor Reg.
Address Expiration / /
PARCEL INFORMATION-12 digit Tax Parcel No. / L / O 1 Fire District
Legal Description
Site Address(include street name and city Fnz� o
Directiops/tosite:
Will timber
rrDDbe cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water(Name) U Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Add -Alt Repair Other Use of Building
Describe proposed construction ►�.� (Z�LY
SHORELINE PROJECTS New Replacement Repair Expansion
Bulkhead Material (concrete, rock, wood, etc.) Length Height
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF PERMIT.
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-1 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-1 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
will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first obtaining approval. be made without first obtaining approval.
f
X Date 7' X Date
FOR OFFICIAL USE BEYOND THIS POINT r-
Accepted by Date Submittal Amount Due Receipt No. 11. ►-I l
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department
Occ Grp Type of Const.
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee Other
UFC Plan Review Fee Other
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES