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NCN N V 7' is cEd me Nd .C� N n� nM 0 0 O f' L O @ X V O) m O) C 0 -O T N N coCL C Tj L -0d m C ILL C c O C N = '- r c O O ry m E mffi a) o 0) y d m c o O� g O m ° m w F 'o m L rn:° 0 > W .� N p ' Q E do v ( E ° = - °' r U 3 N v o d ( � rn @CD C?F o X QS X QmtX XmNo s $ ( m co 0 3 Z�j C y C N = � C C N > m 0 ° c W m 0 v n m 003: omc� a v> a m 01- FORM MUST BE COMPLETED IN INK PERMIT NO.: GR260 PLEASE PRESS HARD MASON COUNTY LAND MODIFICATION PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98684 Shelton 360 27-9670 Belfair 360 2764" Elms 60 2d269 Seattle 206 64-6968 APPLICANT INFO MA PCONTRACTOR INF�O MATION Owner R A00i Contractor Name /O Mailing Add rss a 2 t&q Mailing Address City State 40? J1.7ip Code L City State Zip Code Phone(-jLO)295-357Sbther Ph.C& T Ph.( Other Ph.( Lien/Title Holder Contractor Reg.# Address Expiration ENGINEER INFORMATIO Name � C ��a7 h e Z 75— 3 Address State Zip Code QMZU! J PARCEL INFORMATION-12 di it ax P rce No. l�{�1 Oeqeb Z 4P ict Fire Distr Legal Description e. Site Address(include street name and cit OQ Directions to site: i Will timber be cut and sold in parcel preparation?(Yes/No) Is your property within 200'of the following:Body of Water(Name) /''�9�/��Gf/!Q Saltwater_ Lake River/Creek Pond Wetland Seasonal Runoff Stream,V_Slopes or Bluffs Soft compressible soils L/ TYPE OF JOB-Excavation X Filling Grading Total size of area G ,�Z Size of area to be cleared on lopies ver 1 % 01 stimated amount of cubic yards JM Describe Work cl LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes,source :j � P y /d 5-0J/ O Will excavated materials be taken off site? If yes,destination 5j�� 0- O' Does fill contain potential hazardous materials? I7 10 Has a soils report been completed on site? If yes,include copy. � 0Will proposal result in redirection of any surface water runoff onto adjacent properties? O Will proposed 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 by interceptors,curtain drains or other collection devices? Will the land be replanted upon completion? O Will the proposal result in slopes steeper than those currently on site?Is the site within 200'of a designated shoreline? A 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 GV �' inspection of this project. Acknowledgment of such is by signature below: O 4 < OWNER AFFIDAVIT-1 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 M W ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued t:'V Li will be done in conformance I No changes shall be made without and all work shall be done in conformance therewith. No changes shall first o4don' ppr be made without first obtaining approval.- cc Date Date F'�•1 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 /p�(o. Site Inspection Plan Review Fee A4,Q. 7J Other Public Works Fee Pre-Paid at Submittal a ( ) violation Fee TOTAL FEES