Permit Number: _________________________
MSR: ___________________________________
Date Submitted: ________________________
Permit Tech: _____________________________
Lewis County Community Development
PLACEMENT PERMIT
Signature: ____________________________
Date: ____________
Check one: Owner
Authorized Agent
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
Project Description: ______________________________________
New
Replacement
Other: ______________
Property Information:
Tax Parcel Number: ___________________________ Site Address: _______________________________________________
Owner’s Name: __________________________________________________ Phone Number: _________________________
Owner’s Mailing Address: __________________________________________ Email: _________________________________
Applicant Information (if different): Owner Contractor
Other: _________________
Name: __________________________________________________________ Phone Number: ________________________
Mailing Address: __________________________________________________Email: _________________________________
Project Information:
Contact when permit is ready or more information is required:
Owner Applicant
Contractor’s Name: _______________________________________ Phone: _______________________________
L&I License #: _____________________________ L&I Expiration Date: _______________
Address:_____________________________________________________________________
Installers Name and WAINS#: _____________________________________________ Expiration Date: __________________
Mobile Home Information: Home purchased from: _________________________________________________
____
Make:
__________________________________
___ Model: ____________________________________ Year: ___________
Serial Number: __________________ Price: ____________ Size: ______________ # of bedrooms: _____ Occupancy: ______
Acknowledgment and Permission to Enter:
I understand that County regulations require owner permission for County personnel to enter private property to conduct permit processing, review, and
inspections. I also understand that my failure to grant permission to enter may result in denial or withdrawal of a permit or approval.
By my signature below, permission is granted for representatives of the Community Development, Environmental Services, and Public Works Department
to enter and remain on and about the property for the sole purpose of processing such permits and performing required inspections or reviews.
Prior notification of the date of inspections will take place is: Required Not Required
(________) ___________________ (Must provide phone number where applicant/representative can be reached)
I/We certify that all plans, specifications and other submissions required in support of this application conform to the requirements of all federal, state, and
local codes and applicable laws and ordinances; and I certify that I am either the current legal owner of this property or their authorized representative.
With this document, I take full responsibility for the lawful action that this document allows.
I certify that I have read and understand the limitations and conditions of Lewis County Code and agree to comply with all conditions of approval. I
understand that any permits issued by Lewis County, consistent with the attached site plan, are valid ONLY if construction is in according to this plan and all
other conditions of the permit are followed. By my signature below, I affirm that all the information and documents provided with this application are true
and accurate to the best of my knowledge.
Commercial
Select one:
This project is :
Residential
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