HomeMy WebLinkAboutBLD2022-01251 - BLD CD Environmental Health Review - 9/23/2022 �'-- run MASON COUNTY COMMUNITY SERVICES Permit No:r)ICI"H...!•YG Eir E D
e PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
1. ,��, �'� 615 W.Alder Street,Shelton,WA 98584 S E P 2 3 2022
i. Ill !r
..y . . t j Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
1' " `^y- Belfair:(360)275-4467•Phone Elma:(360)482-5269
-'Y .n 615 W. Alder Street
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:N 64 �UTGf
NAME: 4 ttrE(C7 U 1.l�A$�1F(tJ�ME L NAME ICI-Egpf i. LLc,(tlokig,SF.ttViC )
MAIL1 G ADDRESS: Ul I. ' D - MAILING ADDRESS: I W 4
CITY:f1LL-YA( STATE: ZIP: L CITY• cM STATE:i, ZIP:9/13j.2
PHONE#1: (la>)5 3 JS PHONE: 63 CELL: J
PHONE#2: EMAIL: Q
EMAIL: •Z i1U11eZ '')c>y }rl L&I REGtirfleCIlEtt)+I J EXP.L/j/.ZZ
P Y CO ACT: 9R OWNER 0 CONTRACTOR❑ L OTHER
Z
1 NAME IJt 'F_ i ,J L'!.V l 7-44esIVSIL.TI A!C EMAIL Ct erg/I tea'�5ifl i (.dolt W
MAILING ADDS4 P 0 t7O) 42 CITY STATE 1.G 34-ZIP J
PHONE 3100 5 70 CELL _ z Q
PARCEL INFORMATION: / ,�// // O W
PARCEL NUMBER(12 Digit Number) J I06-52_& )Ot1J ZONING&tiIL/&/O-fle CC
LEGAL DESCRIPTION(O breviatcd) FIR DISTRICT 3
SITE ADDRESS b �E451 T5LAt1t7 De, CITY/YL�� Z
DIRECTIONS TO SITE ADDRESS L7D 12> e4SUi�€ S( 1I�17� 77iLc/ .LFFT/fY' W
46D) AV 1 /6t/r ,SivE Or RPAP
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES)i NO❑ SNOW LOAD:25 psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATERLAKE 0 RIVER/CREEK 0 POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM 0
TYPE OF WORK: NEW ADDITION❑ ALTERATION 0 rt REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) SI K1 r!IL
IS USE: PRIMARY' SEASONAL 0 NUMBER OF BEDROOMS 2 NUMBER OF BATHROOMS / _
HEATED STRUCTURE?
? YES(Whole Bldg)� YES�(Pan[s]of Bldg)❑ NO❑
DESCRIBE WORKAT4 Ai I tOrite U D WORE
SQUARE FOOTAGE:(proposed)
1ST FLOOR/if/6 sq.ft. 2ND FLOOR sq.R 3RD FLOOR sq.ft. BASEMENT sq.ft-
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached 0
MANUFACTUREDff __ �� HOME INFORMATION: AA *4COOPIES OF THE FLOOR PLAN REQUIRED*
j"j,6Gj 4D0D MODEL m 2# 2YEAR 20G2-- LENGTH "jig"
WIDTH 23 4a BEDROOMS 2 BATHS ;Z SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ly4 SEWER❑ / NEW PO EXISTING❑
PLUMBING IN STRUCTURE? YES NO❑ If yes,attach completed Water Adequacy Form .
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOO EXISTING SQ.FT. 0
EXISTING BEDROOMS Q PROPOSED BEDROOMS Z TOTAL BEDROOMS 2__
OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project The owner or legal
representative,represents that the information provided is accurate and grants employees of Mason County access to the above described property
and structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 180 days.
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
4iO4„C( I !, .LV� i Ef�'I�t.i� 4(10AiLl Ti�1�t ���/�..'��Signre of OWN ` ust be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL p� _ , r
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Change of Designer Request
Building Site Address:
460 Treasure Island Dr. Allyn, WA 98524
Parcel Number: 12105-52-00066
Previous Designer/Engineer: Cindy Waite - Septic Designer
New Design Information: Jim Zimny—Advantage Perc & Design
360-516-7287
7178 Windflower PI NW
Seabeck, WA 98380
By signing below, I understand that the original designer/engineer of record is being replaced by the above-
identified designer/engineer.
Elizabeth Nunez a a6o1h IVtfuee 11-17-2022
PRINT NAME SIGNATURE DATE
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