HomeMy WebLinkAboutBLD2022-00406 - BLD Application - 3/30/2022 o""` -`''''2t MASON COUNTY COMMUNITY SERVICES Permit No: Off.'9a®aa-rLiO AID tp
PERMIT ASSISTANCE CENTER:
.. •BUILDING•PLANNING.PUBLIC HEALTH.FIRE MARSHAL
i A tf I.!� = 615 W.Alder Street,Shelton,WA 98584
-:i,`: Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
"r. `'t i` ` `,'. Belfair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: A iv).-1 -t (�C,rw k 3 k &(� • NAME: J .a.p i- ato a ti-fy r: i i..---
MAILING ADDRESS: 3OGS' S �Irl L S1--4 MAILIN ADDRESS: peel L1 ,-2!Ci 3,
CITY: L yttA STATE:IA/A- ZIP. 4/p/ CITY: *, STATE: tk)il-ZIP:(-�!.97
PHONE#1: r aj 3•-lg,"7-7- C�C(-C PHONE: 4.0/4,-75)5 CELL:
PHONE#2: ,95-3"(p51 Cry 24)3 EMAIL:nit i kQ fL11-phi(CE-w%11 .41 It_Q+
EMAIL: L&I REG#pit(2tii1t3F.GD l.L- EXP. ,3 l z. ',20g11
PRIMARY CONTACT: OWNER❑ CONTRACTORS OTHER❑
NAME (YL i kL, .`> ' 7 v) EMAI
MAILING ADDRESS - 3 CITY V4 I, I;V\• STATE 34L ZIP fiS�`J
PHONE r .6s-GAG. '7 3 I CELL
PARCEL INFORMATION: ENV
r, I I 0 N iM E N TA L
PARCEL NUMBER(12 Digit Number) 4 2. I Lf-a?5 "OO f 30 ZONING HE A 1 ) H
LEGAL DESCRIPTION(A„"bb�reviated) FIRE ISTRICT
SITE ADDRESS q I C .. C re'Di- CITY.. 5
DIRE TIONS TO SITE ADDRESS "Kr: /1+^-lit /0/ ND.'77r2SV r,D T77 A/ L,9A.- 1.15.7///ti,fjl)
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES JO❑ SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM AJ
TYPE OF WORK: NEW[ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Resi ence,Garage,Commercial Bldg,Etc.) /eG%SIpG N[e�l'
IS USE: PRIMARYEASONAL❑ NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS a
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Part[a]of Bldg)❑ NO❑
DESCRIBE WORK ?L-//'GG% n ,00tmcirer Lt'j AeD 3,20roJtf-
SQUARE FOOTAGE:(proposed)
�r�11SST, FLOOR/a ' 'sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
Imo'"IIECK 110 sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached 0 Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE 5 /l 4/C MODEL f� It",DJI/ YEAR2.0 LENGTH yS
WIDTH a..t+ BEDROOMS 3 BATHS . SERIAL NUMBER _
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC Ul/SEWER❑ / NEW 1V ' EXISTING❑
• PLUMBING IN STRUCTURE? YESpf 4 NO❑ Af00.4e4tt a ompleted Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOBS EXISTING SQ.FT.
EXISTING BEDROOMS 0 PROPOSED BEDROOMS 3 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 CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT PPLICATION OF 180 DA S OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X
3/3olzZ
I
Si ature of OWNE (Must be el e b the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL . kJ,jirj.. 1
p� �� t
PUBLIC HEALTH b(7)1(7/7_ Ca"`d i lr'\j
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