HomeMy WebLinkAboutBLD2022-00423 - BLD CD Environmental Health Review - 4/4/2022 st`" ``'t+t. MASON COUNTY COMMUNITY SERVICES Permit No:_6td 2 2eZ 1��L3
\PERMITASSISTANCECENTER: 7
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,Ft� BUILDING•PLAW IAlder S�eet S n WA 9 584 SHAL R E C E 1 V E.'
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PhoneShelton (360)427-9670ext352•Fax (360)427-7798 Phone� I�nRO r, ?('?2
N A `I
BUILDING PERMIT APPLICAJ GP: ,�
6- 5 . Alder Si -E;et
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: Ic a DJ My S N
MAILING AIIIDRESS:(d?..O (L(7ak��,SELING ADDRESS:
CITY:('1LIvv :A STATE.. A ZIP:iigS13 ITY: STATE: ZIP:
PHONE#1: �b.4 118C• PHONE: CELL:
PHONE#2: EMAIL:
EMAIL:I)I i r V O.Y1A ?C,�1 Yv 1. Lpt+� L&I REG# EXP. / /_
PRIMARY CONTACT: OVNERA. CONTRACTOR❑ OTHER❑
NAME S144V '�.S 4koiit EMAIL
MAILING ADDRESS CITY STATP n N'\f1.I AP
PHONE CELL ' 'r EN T,�,I
PARCEL INFORMATION: Q�� HEALTH
PARCEL NUMBER(12 Digit Number) I ¶ 1 9-Ls- 0 ZONING
LEGAL DESCRIPTION(Abbreviated) FA) 201139 C, FIRE DISTRICT
4 SITE ADDRESS 4?O S E 0 A I, 01&n iZo( CITY She 1l-o h
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO Nr SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all Char apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF' STREAM❑
TYPE OF WORK: NEW* ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage.Commercial Bldg.Etc.) S ,1 a P
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEAT ED STRUCTURE? YES(Whole Bldg)❑ YES(Part[s]of Bldg)g. NO❑
DESCRIBE WORK MEt.) S S A')
SOUARE (proposed)GE: (propose
1ST FLOORi `b s/q.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE, sq.ft. OTHER sq.ft
GARAGE I S(` ) sq.ft. Attached❑ Detachec9gt CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ks. SEWER❑ / NEWy/ EXISTING❑
PLUMBING IN STRUCTURE? YES NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATIONDRAINS PROPOSED? YES❑ NOD EXISTING SQ.FT._
EXISTING BEDROOMS 0 PROPOSED BEDROOMS VJ TOTAL BEDROOMS 1!L//1
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 are 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 8 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
PE•., •PPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42) —7
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.tu R st qe signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL �I , _`
PUBLIC HEALTH �0� _*Art' GU`A10 N-
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