HomeMy WebLinkAboutCOM2019-00086 - COM Permit / Conditions - 8/28/2019 MASON COUNTY COMMUNITY SERVICES Permit N • —W= 60
PERMIT ASSISTANCE CENTER:
.BUILDING•PLANNING•PUBLIC HEALTH,FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584 RECEIVED
Phone SheRon.(360)427-9670 ext.352•Fax:(360)427-7798 Phone
BeHair.(360)275-4467•Phone Elora:(3W)482-5269
BUILDING PERMIT APPLICATIOAUG 0 9 2019 h oX
PROPERTY OWNER INFORMATION: CONTRACTO TON•
NAME: G�cGICgh.��/�'�4�'J&I /d NAMEWC71J' ve,�c�th (CP ?i,
MAILING ADDRESS: l7 • MAILING ADD, SS: 6rtr ry f/► E [�
CITY: L!ro STATE: ZIP: yfi��' CITY: TTLt STATE: ZIP: /C►
PHONE#1: O — PHO ��+ LL: ,V'(J 6
PHONE#2: bo r' `+l' EMAIL: /r ,� t r �i �+'N vs-► . lt;.o.
EMAIL: CI y N e a, .- ITOk'L'-e OLL&I REG# _ EXP.
41 d✓ PRIMARY CONTACT: C P OWNER� CONTRACTOR❑ OTHER❑
NAME ! U/'"h1—r • EMAIL P h ,
MAILING DRES J. '/✓e CITY Win.6^ SrATE WA ZIP c
PHONE CELL 464 1<71
PARCEL INFORMATION: l n /
PARCEL NUMBER(12 Digit Ntttrl(ier) '3,J� 5-4� _V I ING OI.Y 41 f �,OiMC�l /
LEGAL DESCREMON(Ahhreviatedl r�Yl i t4`1 /�,icw.rs ygv�60y—� DISTRICT #1..rj11'C i#6
SITE ADDRESS_ 1 f E �1'1%,AR-Xct
DIRECTIONS TO SITE ADDRESS —10 T
lor
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO�ff
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Checkoff that appy):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTEERATION❑ REPAIR J OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) /J y-?/ V y,y c AN/Mn
IS USE: PRIMARY V SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(PaH[sI of Bldg)❑ NO'X 1
DESCRIBE WORK Ol"e l-r-7Cz S"d eS.
01
SQUARE FOOTAGE:1prept t-x'(5-11I1�
I ST FLOOR 000sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq,A. BASEMENT sq"ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. 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
PLUMBING IN STRUCTURE? YES❑ NO)J If ves,attach completed Water Adequacr.Form
PERIMETERNOUNDATION DRAINS PROPOSED? YES❑ NCI[] EXISTING SQ;FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS
OWNER acknowledges that submission of inaccurate Information may result in a stop work order or permit revocation.Acknowleidgement of such Is by
signature below.I declare that I am the owner and 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 legal
representative,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 permitlappik:ation becomes null 8 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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
//eeC � C Oi1JTY CODE 14.08.42)
Signature of OWNER(Must be sinned by the OWNERI Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT _ •'2 _�
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
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f` � MASON COUNTY Shelton(360)427-9670 ext.352
DEPARTMENT OF COMMUNITY SERVICES Belfair(360)275-4467
Mason County Bldg. 8, 615 W. Alder Street Elma(360)482-5269
Shelton, WA 98584
www.co.mason.wa.us
REQUEST FOR BUILDING PERMIT EXPEDITION
E
Date:—
Permit No.: �•�
Name: ,o -� �" '� c>veil �� — �r1f 1
F
Mailing Address:
5 /o/ C— , s: IeVLr-p l01:1?
"'o ve) 71 �l✓�f Z V 5`7c
Parcel Number: 3 ? ? ?1 — 'O j 0 C1 7
Site Address: ��
Request due to: 0 Medical Hardship ❑Fire Damage ❑Other ®
Explanation of Hardship: 7 /7 e 12ci elln' jv ems
. C/7r71 W+ e_tCl b'/
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ShlJiv i i�� .>L��1 D��sf '� `✓1'cz'•— i roe �J,� S7`�'�c''7��1�� /00J--J'
Must include supporting documents.This may be a letter from a doctor,insurance claim report, report of fire damage
from appropriate fire district representative or other relevant documentation.
I (WE) understand the Intention of this form to determine and document justification for expedition of a building
permit to alter or reconstruct a structure on the above named property.
Signature Owner/Agent:
Y
OFFICIAL USE ONLY y
Request: [Approved p Denied Date:
Request denied for the following reasons: I
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Signature:
Director of Community Services
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