HomeMy WebLinkAboutMIS97-00125 Dock - MIS Application - 2/12/1997 MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION r
426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670 ���
'LEASE PRINT -——---- O
=1 Owner .SiT:(�N `,/�( �� Phone # s� 75 Z. .10/00 Fire District#
Site Address_ � Z qcl l rn D3((i LJC 0 2 T City. 6 eA9r,-U) -W
Mail Address 69Cf t 4 Be ,6CL AJ D IL44 E'
City -TAOmA St "/p Zip �ZP�fO�i
Applicant Phone# 42.6 3-7 b 7
Applicant Address E 1-1 ci I MUo e uG D Q2 C-br
City 6RA P6J 16-a St cAf lA Zip R -S (o
Directions to Site: W 4 y J 7!j /I�y &-.A/j0A/ ,QF W 70 **16 n( LlG V C-�_r T-4/ AQ�
�I L T L(2, m 1 0 t J LEPT-
' Parcel No. odoLJ- _
Legal Description A1 6O IN(% ' U nl N►( S WC 4/i�_ ADD (� r�.� 4 2--
Indicate by circling the applicable source if any water is on or adjacent to the property site:
saltwater ak river creek stream pond wetland seasonal runoff marsh other
Project Start Date gpJAJG OJ-? Project Completion Date 5P2//U6
Use of Buildiing VQ C X - Describe proposed construction
[�i k 6:4/SRN 6 boor- c.,"X SO A0,0 !0 "K/z L —
'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 issuanoe.
VNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
,ERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON-
:NTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM
-W 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT-
iDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND
ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE-
'RMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
THOUTFIRSTOBTAINING APPROVAL FROM THE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
DEPARTMENT. MENT.
'WNER X BY
E DATE ��/�� -2
Show following on the slte 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
_. am ..m;z ','..a,:: <.�6.+Y.... ,..,. :,.;.'. : , f .e .:.<.: 3.� _ `:�.5..�.ix. a`2'$`°.,�. at,�a b � �ski•a^�'3ad��3�'�`dle! `c;#•�.�¢'z i�:
6�
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning ,e , 1 Iv,0 # 0 APP COND APP HOLD
Building
3-c8-F7
Fire Marshal
ether
special Conditions Fees
42,0 x R•z s= 3, 385- Permit Fee $ 2 Sc
Plan Check 2S C
Other
Other
State Building Fee S O
TOTAL DUE $