HomeMy WebLinkAboutBLD2023-01370 - BLD CD Environmental Health Review - 11/13/2023 MASON COUNTY COMMUNITY SERVICES PernlitNo:ftMbR5-
PERMIT ASSISTANCE CENTER: Q 1 �7 O
.BUILDING.PLANNING.PUBLIC HEALTH a FIREMARSHAL RECEIVED
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext 352•Fax:(3W)427-7798 Phone �1r,D
Belfsir:(360)2754467•Phone Elmo:(360)482-5269 NOV 13 2UW
BUILDING PERMIT APPLIgq#jkQl*,l,@*,ftIWMENTAL
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATMALTH
NAME: - ) 4 SIefiOIrDTn Mtit IW NAME: Dwmr azLI,4, r-
MAILING ADDRESS: RI 6 Mu. MAILING ADDRESS:
CITY:Af-f h-An STATE: q ZIP: 116&tl CITY: STATE: z
PHONE#1: 31a-amil-I tat PHONE: CELL: A�—
PHONE#2: 3(Ip - NHp-bUOf EMAIL: n
EMAIL: rAvLpJW,{M yyygr o B t1 o.4wr al/./o M L&I REG#
PRIMARY CONTACT: OWNER CONTRACPOR❑ OTHER❑ cN.a
NAME EMAIL fli '10t he
MAILING ADDRESS 61 E INt1p r� EArm6 Rdd CITY41(tkrn STATE WA
IPHONE 31/111-A2Q-IL2 r1 CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Ntapber) 3:) I a 1 - It- 0051 ZOTENG R I
LEGAL DESCRIPTION(Abbreviated) (B}1 eF SP4t;6o; FIRE DISTRICT $
SITEADDRESSa3 IC nivr IAlf Lc rwl� �d CFPY.$/I(/-
DIRECTIONSTOSITEADDRESS Nlxcn.t Lake Qd .fip IYluin/w �wrms Q /h IP
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IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NOW SNOW LOAD:---psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM
TYPE OF WORK: NEWT ADDITION❑ ALTERATION❑ REPAIR❑ OTHER [IUSE OF STRUCTURE(Resldmce,Ga.TTage.Commercial Bldg,Etc.) Residence
IS USE: PRIMARR E SEASONAL❑ NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS R.s
HEATED STRU 7 YES(Whole Bldg)] YES(Parlisl oJBhlg)❑ NO❑
DESCRIBE WORK
SOUARE FOOTAGE: (P Preaq
ISTFLOOR_Ly_9j sq.R. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.E
DECK sq.ft. COVERED DECK-4a& sq.ft. STORAGE sq.ft. OTHER sq.&
GARAGE_2,r sq.ft. Attached Detached El CARPORT sq.& 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 SEWER[] / NEW EXISTING
IPLUMBING IN STRUCTURE? YEV NO❑ Ijyes,attach completed WaterAdequRcy orm
PERIMETERNOUNDATLON DRAINS PROPOSED? YES❑ Nl,'f[ -EXISTING SQ.Fr.
EXISTING BEDROOMS ' p PROPOSED BEDROOMS t TOTAL BEDROOMS L�
OWNER acknowledges Mat submission of Inaccurate Information may result in a stop work order or permit revocaton.Admowledgement of such is by
signature below.I declare that I am Me owner and I further declare Mat I am entitled to seceNe this peril and to do the work as proposed.I have k
obtained permission from all the necessary parties,Including any eas s projecte owner o assessment holder or parties of interest regarding this The legal
.No."'nMolt. aal HubnleHlm of lnemunle inbnne4on mq..us N aalso—.oNv orpermit mwlurt AGn,mlespmmmX of hob/
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Anin¢E pertdWm kam all the recessery penes.IhoWIr s soy¢ae¢m¢nl pdEer of pones Isoo—sl repeN This
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lapl¢f¢nwtlue,represents Pat PeInlolmallw pmNOetl is acwMe ME Irmoernplryees of Meson County exess to Neabaw tleadibedp fts
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PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVRY OF THIS
MIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.("SON
�n . COUNTY CODE IC.DB.12(
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DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGSNOTES/CONDIT10Ns
9UIMINGDEPARTN IEN17
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HE Ii
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