HomeMy WebLinkAboutBLD2022-01558 - BLD CD Environmental Health Review - 12/22/2022 r _ 0 ^''"'.t'L1A:1t r2h MASON COUNTY COMMUNITY SERVICES Permit No: l G-2-- 1.')L/��
117 PERMIT ASSISTANCE CENTER:
i BUILDING.PLANNING•PUBLIC HEALTH•FJRE MARSHAL ,
615 W.Alder Street Shelton,WA 98584 C
4 Phone Shelton:(360)427-9670 ext 352•Fax:(360)427-7798 Phone
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''';� ;' Belfalc(360)275-4467•Phone Elmer(360)482-5269 L-, -1� T C f 1
1 �� BUILDING PERMIT APPLICATION 1
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: r L�
NAME:Housing Kitsap NAME: sL v c
MAILING ADDRESS:2244 NW Bucklin Hill Rd MAILING ADDRESS: '/Y\��
CITY:Silverdale STATE:WA ZIP:98383 CITY: STATE: ZIP: 0 11
PHONE#1:360'535-6134 PHONE: CELL: m
PHONE#2:36a535.6138 EMAIL
1 V EMAIL:NailDephousingkilsap.org L&I REG# EXP. / /_ Z
PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER Q°°" •
C1
NAME s K"wp EMAIL klempj@housingkitsap.org _ 73
MAILING ADDRESS 2244 NW Bucklin Hill Rd CITY M. M STATE WA Zip 98383 m O
,, PHONE 3eos35413e CELL 360Se9-92o9 D Z
( Q PARCEL INFORMATION:
• PARCEL NUMBER(12 Digit Number) l 1%2.° SD- 61 OO$ ZONING R-1 P = m
LEGAL DESCRIPTION(Abbreviated)Lakeland Village 10 LOT:21&VAC PTN Blackwell St adj. FIRE DISTRICT S Z
SITE ADDRESS L 0 T 1 co h I t.J pis►..1.- CITY Allyn —4
DIRECTIONS TO SITE ADDRESS 4 g>vr.4 N op E t akr la t,,,L Q a p At W P s r
6tog dF E w, 0,t,L1ra.tL.Ar T. n/ Ar n r
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO 0 SNOW LOAD:30 psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE 0 RIVER/CREEK 0 POND❑ WETLAND 0 SEASONAL RUNOFF 0 STREAM❑
TYPE OF WORK: NEW 0 ADDITION 0 ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.)Single Family Residence
IS USE: PRIMARY[I 'SEASONAL❑ NUMBER OF BEDROOMS •3 NUMBER OF BATHROOMS A
HEATED STRUCTURE? YES(Whole Bldg)fir YES(Parr[s]of Bldg)0 NO 0
DESCRIBE WORK NFW cONSrQuc.-rlotJ ISFR
SOUARE FOOTAGE:(proposed)
1ST FLOOR 1333 sq.ft. 2ND FLOOR /sq.ft. 3RD FLOOR / sq.ft. BASEMENT - sq.ft.
DECK sq.ft. COVERED DECK 1 S. sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE i S? sq.ft. Attached 127Detached 0 CARPORT sq.ft. Attached 0 Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
IMAKE MODEL YEAR_ _LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
1 ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC 0 SEWER I / NEW 0 EXISTING 0
PLUMBING IN STRUCTURE? YES 0 NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 NOD EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS ) TOTAL BEDROOMS 3
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 fora 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
COUNTY CODE 14.08.42) Viir--- dLeI�� b- die �Signature of OWNE (Must be s1 ed by the OWNER) D
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL rl,�(�_
PUBLIC HEALTH ' t16(^L� Lam" D(�(r c r s Ctatiai
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