HomeMy WebLinkAboutBLD2022-01298 - BLD CD Environmental Health Review - 10/4/2022 �7 o
e�� • ,19� MASON COUNTY COMMUNITY SERVICES Permit No: �1d2o2Z 0IL'?�j
PERMIT ASSISTANCE CENTER:
(elkry •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
I' • 615 W.Alder Street,Shelton,WA 98584
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pj Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
y Belfair.(360)275-4467•Phone Elms:(360)482-5269 -n
BUILDING PERMIT APPLICATION t�C�f Iff�Imo}
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: OL,
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NAME: 1 F Y 1 'ef NAME: 6//' i',°?j
MATTING_ADDRESS: l' J r .MAILING ADDRESS: I.. ,(• ,t/fir
CITY: I:- L�' ^ STATEt,A) ZIP:C9i _ CITY: STATE: ZIP: ./ ^,
PHONE#1: (r,t) 7 7 7- -, '//I PHONE: CELL: `J I I'c.'c t
PHONE#2: L) - i9-C) 15 F
EMAIL: '- • (, / G> Yrn=LEG# EXP. / /
PRIMARY CONTACT: OWNER® CONTRACTOR❑ OTHER❑
NAME f of C V N'c--C)4---z+' EMAIL._ •
MAILING ADDRESS 7L) /N r'_.- 1 O l)C4.3 J(}/- ti CITY l (ti' t•i STATE-mod, ZIP`--(c 13i fl'
PHONE 19'-)77/,2‘Ili CELL --(r,2/9(Di . t
2.7 t tl 3
PARCEL INFORMATION:
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PAR('FT NUMBER(12 Digit Number) 3 i t 4 f CDP ZONING cD ✓ 1� l n
LEGAL DESCRIPTION(Abbreviated) FIRE.. TRICT O ' ' I EN T/�L
SITE ADDRESS_DIItECTIONS TO SITE ADDRESS 21 I NE �4 CALL.I�J T� l()t� HEQ j T r ,ENT AL
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑ SNOW LOAD:_psf -
. IS PROPERTY WITHIN 200 FT OF 1Hb.FOLLOWING: (Chet all that apply):
SALTWAIBR❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW g ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Resideico Garage,Commercial Bldg,Etc) (A`( .
IS USE: PRIMARY 0 SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTUK: ? YES(WhalejB�ldg) YES g,ar s)of Bldg)El NO / �dw`
DESCRIBE WORK LooYISIYtICl ad-Acho G�� (/
SOUARE FOOTAGE:(proposed
1ST FLOOR\Scic.,sq.ft 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft •
DECK sq.ft. COVERED DECK sq.ft STORAGE sq.ft. OTHER sq.ft.
GARAGE N. sq.ft Attached❑ D,/nrhed[l{1 CARPORT sq.ft.Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
- ENVIRONMENTAL HEALTH: - k ei-I'L -
SEWAGE/SEWER SOURCE: SEPTIC VI SEWER❑ / NEW❑ EXISTING%
I
PLUMBING IN STRUCTURE? YES) NO❑ if yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ O EXISTING SQ.FT.
EXISTING BEDROOMS L PROPOSED BEDROOMS TOTAL BEDROOMS ?/
i OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocotion.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to rrrcelve this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,inducting any easement holder or parties of interest regarding this pro ed. 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 Ifwork or authorized constriction 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
,----PERM PUCATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42) 071/4 J.27
ignature INNER(Must be signed by the OWNER) Date
IDFXAgTM NTALREVIEW_;: LAPPROVED:=i DATE'`.. _DENIED DATE""TAGSaiOTES/C:O1\NDI1143NS=c_
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL ,�,�p
PUBLIC HEALTH 1'?lI1/.5 _ c�d t� C!"� -
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