HomeMy WebLinkAboutCOM2003-00149 Land Modification Activities Only - COM Permit / Conditions - 10/15/2003 O o
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V/•
PERMIT NO.: GRD
MASON COUNTY
LAND 'MODIFICATION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98684
Shelton 360 27-9670 Belfair 360 275.1" Ehm M0114,824261111 Seattle 206 968
APPLICANT INFORMATION CONTRACTOR INFORn�ATION
Owner E Contractor Name T 2e nef txc d laz 1~c r
Maiiin Address :' z Ato LJ,4 Mailing Address
City j 2 cA E=,r%IW State W Zip Code , !4 City State Zip Code
Phone(. 'bra)?77•4V/t?GlOther Ph.( Ph.( , Other Ph.(
Lien/Title Holder Contractor Reg.#
Address Expiration / /
ENGINEER INFoWmATION
Name M A 12 L Y L. Y(J LI NC -- Phone (.3� 7 q 75-
Address State J&4 Zip Code
PARCEL INFORMATION-12 digit Tax Parcel No. /Z 3 2 / / / r 3 so Fire District ..a.
Legal Description
Site Address(include street name and city
Dirk ions to site: v 't -
Will timber be cut a soldin parcelpreparation(Yes/No)
Is your property within 200'of the following: Body of Water(Kame) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs Soft compressible soils
TYPE OF JOB-Excavation Filling_ _Grading X Total size of area
Size of area to be cleared on slopes over 10% 1VT�IVE Estimated amount of cubic yards .
i
Describe WorkLr)'1=( Uel t)Am d t- r Xi?da 1�fI I ck/dS 2.,
f
LAND MODIFICATION INFORMATION YES NO
Will fill be brought on site? If yes, source
Will excavated materials be taken off site? If yes, destination 0,�
Does fill contain potential hazardous materials? 0 Y
Has a soils report been completed on site? If yes, include copy. 13
Will proposal result in,redirection of any surface water runoff onto adjacent properties? NAMyo o -M
Will proposed work alter where storm water or ground water enters or exits the site? lot
8 Z Nib
Will quality, quantity or velocity of storm/ground water be altered?�5surmaV-t'r'e"an1-rol
Will runoff be collected/controlled by interceptors, curtain drains or other collection devices?Will the land be replanted upon completion? "A '3^.!3
Will the proposal result in slopes steeper than those currently on site?
Is the site within 200' of a designated shoreline?
NOTICE: THIS PERMIT BECOMES NULL A VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT CO .MENCtD WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.'
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNL!2 AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
will be done in conformance ther .h. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first obtainlaVproval. be made without first obtaining approval
X
j. " ,�'��►" X Date
-Date � .�
FOR O ICIAL USE BEYOND THIS P INT
Accepted by Dat �ubmiftal Amount Due 4101 1,7- -Receipt No,� /e.�
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department
Planning Department
Public Works Department
Fire Marshal
FEES
Grading Permit Fee Site Inspection
Plan Review Feed Other I 1 f ,`r `
Public Works Fee Pre=Paid Submittal
Violation Fee TOTAL FEE `
49 PERMIT NO.: GRD
MASON COUNTY
LAND'MODIIFICATION P9RMIT APPLICATION
420 W. ffarAP Q.,Box 1%�,WA 98ti8wt
Shelton 80 Y7-9670 SelfaIr 3610 Sw 67 Seattle
A�'PLIC NT INFORMA'TION � �3g1�RA 't�JF#INFORMATIONOwner O , 05R Contractor Name r Ae 17 lxc.d la.Ar
Maili Address Mailing Address
City % ,gy p/State Zip Code 2113/Q City State Zip Code
Phone 9777�q/000ther Ph.(. 1 Ph.( , Other Ph.(. )
Llen/Title Holder Contractor Reg.#
Address Expiration
ENGINEER INFORMATION
Name , MA��. �_._ YouN�' Phone (3J60 .2 --�7�,L 75�
Address State Zip Code'
i
PARC UNFORMATION-12 digit Tax Parcel No._[2-3 a / 175 O Fire District .2
Legal Description
Site Address(include street name and city LQ -
Dir ions to Site:s
-/90 rA i
Will timber be cut arlid sold in parcel preparatio (Yes/No)
Is your property within 200'of the following: Body of Water( ame) Saltwater
Lake . River/Creeki ,,,,�_ Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs Soft compressible soils
=b
TYPE O,F JOB -Excavation Filling g Grading X Total size of area
Sizefif area to be cleared on slopes over 10% � Estimated amount of cubic yards exe,
Des?Eribe Work e/ - G,
LAND MODIFICATION INFORMATION YES NO
Will fill be brought on site? If yes, source
Will excavi"d materials be taken off site? If yes, destination
Does fill contain potential hazardous materials?
Has a soils:report been completed on site? If yes, include copy. Z
,Will proposal result in redirection of any surface water runoff onto adjacent properties?_ O 37`. 9
«.,. Will proposed work,§lt0.where storm water or ground water enters or exits the site? �lS nndd
Will quality, quantity orvelocity of storm/ground water be altered?fir-/r�te)rr "FrCantfo/ a% C
Will runoff be collected/controlled by interceptors, curtain drains or otitter collection devices?
Will the land be replanted upon completion?
Will the proposal result in slopes steeper than those currently,on site? `
y Is the site,withiin 200'of a.designated shoreline?
NOTICE:IMS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED 1S NOT COMMENCED WORN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
Information;provided is accurate and grants employees of Mason County access to the above described property and structures for review'and
Inspection of this project. Acknowledgment of such is by signature below:
OWNERti AFFIDAVIT-1 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that 1 am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
win be done inmonformance ther 'h. No changes shall be made without and all work shall be done in conformance therewith. No change§shall
first provaL be made without first obtaining approval
X ate - +'2 V—�V3 X Date_,
FOR O ICIAL USE BEYOND THIS P I T
Dat ubmittal Amount Due ^' Receipt No
Accepted by
Dl+?PARTIVIENTAL REVIEW o o DENIED CONDITION CODES
Building.Qepartment
Planning Department
Public Works Department '-
Fire Marshal „
FEES
Grading Permit Fee a Site Inspection
Plan Review Fee �.(� Other n h
Public Works fee Pre=Paid' Subfrilttal
1.Violation Fee TOTAL FEES