HomeMy WebLinkAboutMIS93-00408 Cancelled Foundation - MIS Permit / Conditions - 8/2/1993 D�p
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MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
PLEASE PRINT#1 Owner L :ACeX\ C�� Phone # q 2-7-1 "r'
1 I v Fire District
Site Address r t C3��{ m�WWICSQr1 6Zc city-
Mail Mail Address —_-
City St Zip
Applicant Phone #
Applicant Address
City St Zip
Directions to Site: a-q' VIQk CY1 Q�� ���� .Z rU
Nq pieaer) davin Ckpq Cc I cigQ-V b�1 Qyl IP,v pot"(
1', neS op 4a coy n r 1 -the n r ha--
#2 Parcel No. ?���,� s—_ 2 Z_ 90 /3 1 Z
Legal Description �10 Z ri r% fJL'i ►V IV
#3 Indicate by circling the applicable source if any water is on or adjacent to the property site: k/bIrl
saltwater lake river creek stream pond wetland seasonal runoff marsh other
#4 Project Start Date v�J Project Completion Date Noyl
#5 Use of Buildiing Describe proposed construction
1'Yly b 1_e !InCJ rn �. c a
'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 CON-
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 CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUT FIRSTOBTAINING APPROVAL FROMTHE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. MENT.
X OWNER X BY
DATE Z' 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 directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building
Fire Marshal
Other
Special Conditions Fees
Permit Fee $
Plan Check
Other
Other
State Building Fee
TOTAL DUE $