HomeMy WebLinkAboutMIS93-00373 Pre-Inspection - MIS Application - 7/14/1993 MASON COUNTY
7//4/g3 PRE-INSPECTION APPLICATION
/eeGe4p 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670 0��ENERA� SER���ES
46no- $25.00 Fee Required prior to inspection G
PLEASE PRINT I
#1 Owner JDIUi �� J,4 es 2i Phone# ��Z -V// z
Site Address 410 (rX,1e A c kd• A07- l 9--5— City S,h P A ` 2-fV'
Mail Address 4AW S fi m e _
City f St Zip
Applicant U rU Phone # 4)/o - hV//LI
Applicant Address )E0140 /_J e )/Yrl e
City 5 / 7—C A) St Zip
#2 Parcel No._�);� 3 Legal Description L- l`n,5
#3 Purpose of Pre-Inspection 04.5_USS P4 AC,9"EA1r
#4 Use of building N°_�
#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:
�%�'� Cy.. •H c ' &Mt 4 e�1 /���-►2� Cie CD 71�s���
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.
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Applicant Signature Date
i
FOR OFFICIAL USE ONLY: Accepted by: Date:
Receipt No. Referred To j
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Proposal Proposal
Approved Denied
Planning:
Building:
Fire Marshal:
Special Conditions
' 'ee `:
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