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(360)539-7610-FAX(360)491-6308 A Demolition Permit - �-� �`' ' � ,•' South Bend Office(360}942-2137 RCA Port Townsend Office(360)338-6419 A www.ORCAA.org ❑ Emergency PROPERTY OWNER Name: Glenn Miller Phone: (360)275-5145 : Email: gsmiler6l@outlook.com Mailing Address: PO Box 841 City: Belfair State: WA Zip 98528 Site Address: 81 NE Makela Road City: Belfair County: Mason Zip 98528 DEMOLITION CONTRACTOR Contractor Name: Self Phone: (000)000-0000 Email: Site Contact Person: Phone: DEMOLITION INFORMATION #of structures being demolished: 1 Start Date: 6/1/2016 Expiration Date: 6/1/2017 - - --- - --- - -- - - - ---- -- ---- - - ------- Asbestos present? 0 Yes W No Survey attached? © Yes ❑No All identified asbestos was removed under !: Asbestos Permit# N/A DEMOLITION PROJECT CATEGORY W Complete Demolition El Training Fire Fire Agency,Contact, Phone: El Renovation,Alteration, Remodeling,Maintenance, or other Construction I do certify that I am the owner,authorized agent of the owner,or authorized contractor for the property subject to this ORCAA application/permit.1 authorize ORCAA staff to enter the property listed in this application at reasonable times for purposes of inspecting the work that is the subject of this application/permit and to ensure compliance with permit conditions,applicable laws and regulations.I understand that granting of this permit by ORCAA does not authorize anyone to violate federal,state,or local laws or regulation pertaining to activities associated with this permit.I have read and will abide by the conditions set forth in this permit and any addendum thereto. I do certify under penalty of perjury under the laws of the state of Washington that the information in this application and supplemental data is,to the best of my knowledge true,accurate and complete. Electronically submitted by: gsmiller@outlook.com Permit Conditions Date Application Received Payment Info. Approved Asbestos Permit Permit# ASB „ Total Fee: $35.00 Disapproved Demolition Permit: 5/27/2016 Receive date: 5/27/2016 Review date: 5/27/2016 permit# 16DEM004368 Reviewed by: MS Agency Use Only Agency Use Only Agency Use Only Agency Use Only OVER K co MASON COUNTY PERMIT NO.J DEPARTMENT OF COMMUNITY DEVELOPMENT BUILDING•PLANNING•FIRE MARSHAL WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352 _ Mason County Bldg. 8 (360)275-4467 Belfair ext. 352 18.14 615 W.Alder Street (360)482-5269 Elma ext. 352 Shelton,WA 98584 DEMOLITION PERMIT APPLICATION r OWNER INFORMATION: CONTRACTOR INFORMATION: NAME:G LE" 0 F- M f L-L, NAME: MAILING ADDRESS: ?Q 3 0k -,�y I MAILING ADDRESS: CITY: ��L=L�_� (� STATE: ZIP: �' �� CITY: STATE: ZIP: PHONE: CELL: PHONE: CELL. EMAIL: EMAIL : L&I REG# EXP. PARCEL INFORMATION: PARCEL NUMBER(12 DIGIT NUMBER) /013 Q-0-/ '3 O / O FIRE DISTRICT S LEGAL DESCRIPTION(ABBREVIATED) : ,$g j P SITE ADDRESS <9I NL r✓1ffj, ',�/q {Zp CITY 3E-,-F�9-c 2 DIRECTIONS TO SITE ADDRESS: FiZo r-,, 3 a Lt=r} c 2 Gj p &3 o e.71t o o-r H-F—1pL O i�z"-F-I c!Q H L'i YT IS PROPERTY WITHIN 200 FT: SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND[] WETLAND❑ SEASONAL RUNOFF[] STREAM ❑ DOES PROPERTY HAVE SLOPE(S) WITHIN 300 FT OF THE PROJECT- GREATER THAN 14% YES[] NO IF YOUR PROJECT IS LOCATED ADJACENT TO OR WITHINANAREA THAT IS LISTED ABOVE, PLEAS CONTACT THE PLANNING DIVISION OF COMMUNITY DEVELOPMENT PRIOR TO DEMOLITION TO ENSURE REDEVELOPMENT. USE OF STRUCTURE BEING DEMOLISHED(RESIDENCE,GARAGE ETC.) lc c 7,E#J C-E— HOW WILL THE DEBRIS BE DISPOSED OF ? i tl-K EN PROVIDE A PLOT PLAN INDICATING LOCATION OF STRUCTURE TO BE DEMOLISHED S F 4 7- -P'�-c t--E]� OWNER/CONTRACTOR acknowledges 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, owners legal representative, or contractor. I further declare that I am 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 authorized agent 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&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 IS BY MEANS OF INSPECTION. INACTIVE OF�H� MIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. r L Signature of Applicant dite X C�4-LN tJ /OWNE&/ REPRESENTATIVE/CONTRACTOR Print Name (CIRCLE TO INDICATE) DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGSINOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT