Lewis County Community Development
Signature: __________________________________________ Date: ____________________
Check one: Owner
Authorized Agent
GENERAL INFORMATION
Acknowledgment
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.
Property Information:
Tax Parcel Number (s): ____________________________________________________________________________
Zoning: ____________________________________ Acreage: ____________________________________________
Site Address: ____________________________________________________________________________________
Owner’s Name: _______________________________________________________
___________________________
Owner’s Address: ________________________________________________________________________________
Owner’s Phone Number: __________________ Owner’s Email: __________________________________________
_______ Quarter Section, Section _______, Township _______ North, Range _______ East/West (Circle One)
Applicant Information:
Name: _________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
Phone Number: __________________________ E-mail: ________________________________________________
Surveyor/Engineer or Other Contractor Information (Attach additional sheets if necessary):
Name: _________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
Phone Number: __________________________ E-mail: ________________________________________________
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
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