HomeMy WebLinkAboutBLD2022-00664 - BLD Application - 10/5/2022 MASON COUNTY COMMUNITY SERVICES PeTmit Nth. 21)22•- bftbi Lj
PERMIT ASSISTANCE CENTER: , k.j'
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSH �' p /
615 W.Alder Street,Shelton,WA 98584 MARSH
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Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
Be/fair(360)275-4467•Phone Elmo:(360)482-5269 Wer sire t
BUILDING PERMIT APPLICATIO f�5' J
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: ✓ NAME:
MAILING ADDRESS:i ,2L 112: St- MAILING ADDRESS:
CITY: 'ref a STATE:le.J A:ZIP: _t1L.6 CITY:__________ STATE: ZIP:
PHONE#1: PHONE: CELL:
PHONE#.2: EMAIL:
EMAIL: _x\/C14 L¢@_ C_C pw. L&I REG# EXP. / / II
PRIMARY CONTACT: OWNER❑ CONTRACTOR 0 OTHER❑
NAME 1 L4 C44- EMAIL -( A.1PVL6C.GIC •ea-d1/�
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION:PARCEL NUMBER(12 Digit Number) 4ZR5^ _ (___`},7 ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESSO C ILjl - Ic.t O{ - CITY �Y1__ ✓\
DIRECTIONS TO SITE ADDRESS
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 all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW ADDITION❑ ALTERATION❑ REPAIR❑ OTHER 0
USE OF STRUCTURE(Residence, age,Come cial Bldg,Etc.) Si diiL
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(WholeBldg f YES(Parr[s]ofBldg)pQ NO❑
DESCRIBE WORK
SOUARE FOOTAGE g1c. ) tt $y
1ST FLOOR 2.1Q-S sq.ft. 2ND FLOOR_____ sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK s .t1. COVERED DECK sq LTORAGE sq.ft. OTHER sq.ft.
GARAGE '7V sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached 0
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 0
PLUMBING IN STRUCTURE? YES ��/ NO❑ If yes,attach completed WaterAdequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOD 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 permittapplication becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period ci 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
COUNTY CODE 14.08.42)
) 2L_ LL
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMEI TAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
Mason County WA GIS Web Map
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10/3/2022, 2:02:02 PM 1:1,534
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