HomeMy WebLinkAboutBLD2022-00540 - BLD Application - 4/28/2022 • MASON COUNTY COMMUNITY SERVICES Permit No: 3k121J.Z11—LY)s
PERMIT ASSISTANCE CENTER: R E C E I V
), •
BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
•1 I• 1131G W.Alder Street.Shelton.WA 08584
.1.111( 1f*- I Phone Shelnn:(300417-98TO sat.552•Fax (38o)427-77PB Phone'110 APR 2 2022
` BeRNr:(380)1T5-448T•Phone Etna:(38O)482.82e9"'.ILiYY �
BUILDING PERMIT APPLICATION 1 A r Street
PROPERTY OWNER INFORAIA•17ONI CONTRACTOR INFORM TIONI
NAME: C ' r S NGrrL \Un NAME_ , lkftns
MAILIN r ADDRESS: .7o1G 1 444 Sir pith SE MAILI O ADDRESS: 92 Ka(G SQQi,4rf IT/
CITY: P►ryGllup STATE 0, ZIP: g$37,I CITY:+-7awd n,5f. STATE: Wet. ZIP: 9GL46
PHONE HI: o?S3 , 5 4 1 b 3 PHONE: 14,0 ?„,Lo-if
PHONE M2: EMAIL: ktl.14"c r VICO.-Ihot tS.CGtIa-
EMAIL: C1'\fS -karrtSun R(Awl(Oci•,rke f L&I RL'Cifl EXP. / / j
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L I PRIMAR CONTA 1 OWNER❑ CONTRACTOR[r OTHER❑'
� r' ` MAILING ANAME DDRESS Q �alr. Se..kr, PtGfe CITYLP -7sq•arn)PAAASTATE WA ZIP96156
7 J PHONE Zia, tart Ll'1 S CELL
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TLU PARCEL INFORMATION:
Ct y PARCEL NUMBER(12 Digit Number) y.e7 P 3 SO O0C / ZONING
LEGAL DESCRIPTION(Abbreviated) S F yi FIRE DISTRICT
Z SITE ADDRESS Xo4aq (V US tl;5‘.nl...a•j in CITY Sint The\
w DIRECTIONS TO SITE ADDRESS I A I }v a Dog H it.,1.04 101
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%; YES(3 NO 0 SNOW LOAD psf
IS PROPERTY\ I IN 200 IT OF THE F OLLO PING: (Cluck all that appl,J:
SALTWATER LAKE❑ RIVER/CREEK[POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW B"ADDITION❑ ALTE.p•' i .- ' ❑ OTHER 0
USE OF STRUCTURE(RnIdno ••r.Grnor.Caxrrrc7alalJg R.e eS+l�e/YGt (a.) G.444CLIA4 C1 ,rW
IS USE: PRIMARY 5 SEASONAL 0 NUMB B ` t a:P s.r - I. HER OF BATHROOMS
HEATED STRUCTURE?-YES Of Sole e [y YES(Pan(:J a aide)0 NO❑
DESCRIBE WORK TIO FYl E. b
KUARE FOOTAGE. ,,,.r, f
1ST FLOOR t g.7 eZ sq.ft. 2ND FLOOR Seta sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft-
i DECK sq.ft. COVERED DECK)01 sq.ft. STORAGE sq,ft. OTHER sq.ft.
• GARAGE sq.ft. Attached❑ Detached❑ CARPORT Sa 8 sq.ft .41ached Er 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 Q- SEWER❑ r NEW❑ EXISTING 0
PLUMBING IN STRUCTURE? YES Er- NO 0 1[yes.attach completed Witter Adequacy Form
PERLMETER/FOUNDATION DRAINS PROPOSED? YES Er NOD EXISTING 5 � _
EXISTING BEDROOMS — PROPOSED BEDROOMS e2 TOTAL BEDROO IS62
OWNER acknowledges that submission of inaccurate Won-nation may result in a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I are the owner and I further declare that I am entitled to receive the permit and to do the work as proposed.I have
obtained permission from al the necessary parties,Indudirg any easement holder or parties of Interest regarding this project.The owner or legal
representative,represents that the hfonnadon provided Is accurate and grams wnpfoyees of Mason Courtly access to the above described property
and st ucture(s)tdrreniew and inspection.This perm4'applutgn becomes null&roil If work or authorized construction is nd commented within 180
days or if construction work is suspended fora period or 180 days.
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF TM
PERMIT APP TION OF 180 DAYS OF MORE WIL USE THE APPUCATION BE E)(PIRED•(MASON
+` 90E 14.00.42)X(''':---- —t- .,-7)P-Z-e7.. /4-//70.4;?. 2
Signatu (Must be sign v the OWNER) ifits
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDmONS
BUILDING DEPARTMENT —
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH �jIg42-- (p ilk.
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