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CD O m v O 0 0 (np CD _ D CD r. < O C o CD 3 0 2 � g m o -d �, _ � m ? o o 0CD � �vmm 3 O m oo d Q O N C E � Cl m n m CL cn y v S 3 v m SCD CU .r# O m N `.< m S ` OL m v m = � :E (Dc n) v �, v sm � m O m' X j' n N = co N a — r« o � �' c CD N O (mA - Cp is S cr m m �' C- c�-oi FORM MUST BE COMPLETED IN INK { ; PERMIT NO.: GRD C PLEASE PRESS HARD MASON COUNTY C� Cyr��-7 LAND MODIFICATION PERMIT APPLICATION V 426 W.Cedar/P.O.Box 186,Shelton,WA 9N" Shelton 360 27.9670 Beffair 5 Elma 60 -5269 Seattle APPLICANT INFORMAjJON CONTRACTOR INF RM4TIION _ e1 Owner Ok AWl t✓ I L L, . L),C_ Contractor Name Maili Address -0. Mailian Address O City State . Zip Code cAXq2,K City tate Zip Cod Phone(, ] SO her Ph. Ph. 7 Other Ph. Lien/Title Holder Contractor Reg.# Dh L VV Address 1 2 i r Expiration ENGINEP INFORMATION A `3bD Name 11per Me__6_A_L1_QJt_r_ {+• Phone Address Statej&& Code Z PARCEL INFORMATION-12 digit Tax Parcel No. I A 332 / 150 /q004O Fire District Legal Description M 8• T'NVEI EJ2`S Op S -1 T)J I S 100 Site Address(include street name nd city N MAAJ i> ` iELF 12 LU Directions to site: Will timber be cut and sold in parcel preparation? (Yes/No) NO Is your property within 200'of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Soft compressible soils TYPE OF JOB -Excavation Filling Grading_ Total size of area Size of area to be cleared on slopes over 10% KA5� Estimated amount of cubic yards Describe Wo lw?-+ Nr_ 0j£ 4�(k_< 104 I-b OA--) I'('E LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes, source 0 Will excavated materials be taken off site? If yes, destination Does fill contain potential hazardous materials? 17 Has a soils report been completed on site? If yes, include copy. � E3 Will proposal result in redirection of any surface water runoff onto adjacent properties? a A Will proposed work alter where storm water or ground water enters or exits the site? O Will quality, quantity or velocity of storm/ground water be altered? a Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? Will the land be replanted upon completion? Will the proposal result in slopes steeper than those currently on site? Is the site within 200' of a designated shoreline? E3 NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED 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: OWNER AFFIDAVIT-1 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 therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall f aining approval. II/, eate be made without first obtaining approval. A- 0 Z S X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Planning Department Public Works Department Fire Marshal FEES r it Fee Site Inspection Fee Other Fee Pre-Paid at Submittal TOTAL FEES tPRM'IT NO.: GRD MASON COUNTY LAND MODIFICATION PERMIT APPLICATION �Un 426 W.Cedar/P.O.Box 186,Shelton,WA 98684 Shelton 360 427-9670 Belfair 360 275-4467 Elma(360)482.6269 Seattle 206 464.6968 APPLICANT INFORMATION CONTRACTOR INF RM TION Owner 'RQr-t t,,g PILL . L L (_.- Contractor Name �E+ rN v", Mailing Address � Q. -_C Mailirl9 Address • 9-C L City l -A1(L State�_ Zip Code 2 City�` L A Ir tate INA. Zip CodeG 2 Phone�')'i1.-(?SU? Other Ph.C?) Ph.( �b� ) - 7 Other Ph.( Lien/Title Holder - t 1e V-0 C Contractor Reg.# ft L Address JUql 1(l IL2 koe I C -�. Expiration _jLT _/ ENGINE R INFORMATION Name Phone Address •£ f-CAC k State tL& Zip Code 1 2- PARCEL INFORMATION-12 digit Tax Parcel No. l 33:2 / 150 / p0 O Fire District Legal Description M 8. Tit Ll5:1Z,S qgA � GAlz TRS I,-or,.`D' 61: S 1 a 9�� PT)t V I S 100 e Site Address(include street nam nd city2 W_ E RMPrN© CE FI1 Li p' p AiQ W Directions to site: C' A-y1E' ?i"I`�r Of S� O 4112 Ar R Ory-S rICS Ph I ( Will timber be cut and sold in parcel preparation? (Yes/No) NO Is your property with1h200' of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Soft compressible soils TYPE OF JOB -Excavation Filling Grading_ Total size of area C:G 2 Size of area to be cleared on slopes over 10% LCNX Estimated amount of cubic yards Describe Work LZ i T-e- < ~MUE IP, IUJ LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes,Source 0 )iL Will excavated 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. IS5 dd Will propos result in redirection of any surface water runoff onto adjacent properties? lam+ Will propose work alter where storm water or ground water enters or exits the site? Will quality, quantity or velocity of storm/ground water be altered? 0 Will runoff be collected/controlled try interceptors, curtain drains or other collection devices. 0 Will the land be replanted upon completion? 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&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED 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: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT4 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 will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall fi taining approval. be made without first obtaining approval. �0 hm k X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Planning Department Public Works Department Fire Marshal FEES Grading Permit Fee Z3 Site Inspection Plan Review Fee 2e�__ Other Public Works Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES i CIC61- PERMIT NO.: GRD MASON COUNTY LAND MODIFICATION PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427.9670 Belfair 360 275-4467 Elma 360 2-5269 Seattle 206 464-6968 APPLICANT INFORMATION CONTRACTOR INF RMATION Owner = . ±Lys L 1_ C _ Contractor Names Mailing Address i _ Mailing Address t7,t City EL I V A i i' State l,�LL Zip ode C ? ' City F k i,f'A i,t- tate(Zi_ Zip Code'+; Other Ph. �. �:` � Ph.( ,_)- , "",,i e P- Oth r h.(� Lien/Title Holder f."I Contractor Reg.#� .4 r L"v Address I q-) F a. �` 1 T Expiration / I , a ENGINEER INFORMATION / Name k ..-r t � (-.t r i' Phone ( ( v ) Address 'rle"E i /' State Zip Code PARCEL INFORMATION-12 digit Tax°Parcel No. _t,Z0 /qU040 Fire District Legal Description S4M b. TfWLVZ'Sf G SP 4a S Iw Site Address(include street name and city t 2 { :Mctions to site: v ; r . . Will timber be cut and sold in parcel preparation? (Yes/No) ill Q ` Is your property withM 200' of the following: Body of Water(Name) J Saltwater Lake River/Creek Pond Wetland Seasonal Runoff—?','—Stream Slopes or Bitffs Soft compressible soils TYPE OF JOB -Excavation Filling Grading_ Total size of area P.e + t' Size of area to be cleared on slopes over 10% ii : Jr Estimated amount of cubic yards Describe Work i.i tis` r C ~' i i t + t k't �- I T1 ILI r r ' h LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes, source 0 Will excavated materials be taken off site? If yes, destination Does fiU contain potential hazardous materials? 13 Has a soils report been completed on site? If yes, include copy. Will proposal result in redirection of any surface water runoff onto adjacent properties? }� Will propose6 work alter where storm water or ground water enters or exits the site? Will quality, quantity or velocity of storm/ground water be altered? J14 Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? Will'the land be replanted upon completion? 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&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED 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: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I 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 therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall _ first..obtaining approval. be made without first obtaining approval. � f t I K i ' " Tt Date X Date --'' FOR OFFI IAL USE BEYOND THIS POINT r. r Accepted by Date Submittal Amount Due r r' Receipt No. EPRRTIIA_NTAL REVIEW' APPROVED DENIED C NDITIQN COQES Building Department Planning Department o Public Works Department Fire Marshal FEES Grading Permit Fee Site Inspection Plan Review Fee Other Public Works Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES