HomeMy WebLinkAboutPre-Inspection - MIS Application - 8/25/1993 MIS
MASON COUNTY
PRE-INSPECTION APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
$25.00 Fee Required prior to inspection j7��C�5� (jA14 O"
PLEASE PRINT 1 Yk{S#4, t _4_) rL C
#1 Owner I 1 ! ��y t L] (3-q k Phone # `�5' -Sv y8
Site Address City B f k i yr
Mail Address Rr) zyX 528
City L Q St UJ A Zip 4? e I S ol
Applicant Phone # �0
Applicant Address Jo i g 40
City LpL AC(_ fA St t'JA- Zip
#2 Parcel No. ,2-Z:130 - -5 I _- 00M 11)
Legal Description R4'A4S (jam k)Q. V
#3 Purpose of Pre-Inspection 614 V (' (C7 (
#4 Use of building St W, rk\rk"
#5 Indicate by circling the applicable source if any water is on or adjacent to subject property:
saltwater lake creek stream marsh river pond wetland seasonal runoff other
Directions to Site: 1 010 4 4v
Show following on the site plan below: Lot Dimensions, Existing Structures, Structure Setbacks, Water Lines, Septic Systems,
Flood Zones, Wells, Shorelines, Easements, Name of Flanking & Fronting Streets. Indicate directional by N, S, E, W, etc.
Applicant Signature Date
FOR OFFICIAL USE ONLY: Accepted by: Date:
Receipt No. Referred To
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Proposal Proposal
Approved Denied
Planning:
Building:
L ,
IJ
Fire Marshal:
Special Conditions