HomeMy WebLinkAboutMIS96-00852 Cancelled Foundation - MIS Application - 11/26/1996 MIS
MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186 Shelton WA 98584. 427-9670
PLEASE PRINT X
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Address NF— gNb`6 65A2 L./Z- L�Tsw � (�O City �Is,LFA1YL
Mail Address �.
City EI&ILVAie St WA Zip
Applicant SAw..c A S A 4nve- Phone# S'A�t
Applicant Address SA►,{
City St — Zip
Directions to Site: F"��►�. (SeLFaPR %o D OLD (Sr-.0CAirs "%.I . To AnA)2 Cl2ok
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#2 _arcs+No. "Z Z 3ot1 - '7 O o J O
Legal Description (� o+.S11-Nt±J 20
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#3 Indicate by circling the applicable source if any water is on or adjacent to the property site:
saltwater lake river creek stream pond wetland seasonal runoff marsh other
#4 Project Start Date <,. = Project Completion Date
#5 Use of Buildiing Describe proposed construction
"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 DATE
Show following on the site plan
Lot Dimensions Flood Zones l
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements t`
Septic Systems . Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
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FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning u/ �j�'1,wGlti�„I�f�(/�la�-r�iJ APP COND APP HOLD
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Building
Fire Marshal
Other
Special Conditions Fees qo 6 v
Permit Fee $
Plan Check
Other
Other
State Building Fee
/! D
TOTAL DUE $ 'Z