HomeMy WebLinkAboutCOM2021-00041 Annual Review - COM Application ' MASON COUNTY COMMUNITY SERVICES Permit No: Com a6al-- [J I
PERMIT ASSISTANCE CENTER:
BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax.,(360)427-7798 Phone
Belfair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
J NAME: P e,- �`� f'0"'4 C" NAME:
MAILING ADDRESS:. 6'C R. & MAILING ADDRESS:
CITY: Ae-/frh STATE: 6-.A ZIPRH-1-�1 CITY: STATE: ZIP:
PHONE#1: _ &2--Z2ra PHONE: CELL:
PHONE#2: - EMAIL:
EMAIL: -pce rL q .Ca'— L&I REG# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑
NAME / o4,9-f " Ar�J `( EMAIL SOH `—
MAILING ADDRESS 0ZZ t-.k. -3 CITY• - Y8r-t STATE 44 ZIPS
PHONE CELL
PARCEL INFORMATION: `
PARCEL NUMBER(12 Digit Number) f�� ' 3f—'boo IV ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESSSf ,2. LL, -i P, 3 CITYS�/r1 4
DIRECTIONS TO SITE ADDRESS
�2 7 y' e(l/c`-
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑ SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (check aII that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Part[sl of Bldg)❑ NO❑ /1
DESCRIBE WORK u ,cdrA t7 c77
SOUARE FOOTAGE:(proposed) p1zw Opt'. 1 f
1ST FLOOR sq.& 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.fL 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 SERLAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO❑ lfyes,attach completed Water Adequacy Farm
PERD ETERNOUNDATION DRAINS PROPOSED? YES❑ NO[] 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.Acknowledgement 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 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�4�tT1Q€JkTMN OF WORK ON THIS PERMIT Y MEANS OF INSPECTION. INACTIVITY OF THIS
ty r APPLICATION OF 180 DAYS OF MORE WILL f' E THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 8.42)
�ptOWNER jimadbytba g*NE1Date
TMENTAL REVIEW APPROVED;. E __DENIED DATE TAGS/NOTES/CONDITIONS.
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BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
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