HomeMy WebLinkAboutCOM2022-00105 - COM CD Environmental Health Review - 12/27/2022 � MASON COUNTY COMMUNITY SERVICES Permit No: )Y) ' ' 1t h C�
PERMIT ASSISTANCE CENTER: r-�( — I '
BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL 1 \ . , ,
a. d f'y �. v C•1• 615 W.Alder Street,Shelton,WA 98584 e�
.• - _..:- 11 Phone Shelton:(36 427-9670 ext.352•Fax((36�)427-7798 Phone 0 E CO L'1 �VLL O"�
Bellair(360)275 446 7•Phone Elma: 360 482-5269 '/ �[
g•rug ! 3
BUILDING PERMIT APPLICATION 61 et "?
PROPERTY OWNER
" INFORMATION: CONTRACTOR INFORMATION: _ E I V E :.
NAME:NOM 1.p1/ Fire �1y� 4.5 NAME:
MAILIN AD RESS: -'odo( 11 10 MAILING ADDRESS: 7
CITY:S p�tt)n STATED$ ZIP:q$SDI CITY: STATE: ZIP:
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PHONE#1: 3 G p- L0),( -5-533 PHONE: CELL:
PHONE#2: 3f►O as $73o EMAIL: ,ilLiAN Alder Street
EMAIL: Zi 0A81Yrii��G/ii(NCO L&I REG# EXP. /_i_
PRIMARY CONTACT: OWNER❑ CONTRACTOR 0 OTHER K.
NAME tStis+lA '',,refer- EMAIL I pOe. 1!i-�CAI .OTC
MAILING ADDRESS 15, dOi 1gto CITYSADI STATE(,,) ZIP 8tl
PHONE 3Lei— �4 ..S, it) CELL 3L0—Aa4 ^Ff)5c
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) a a 133 bQ to OO.O ZONING IZ 5
LEGAL DESCRIPTION(Abbreviated) jA FIRE DISTRICT •SITE ADDRESS r CITY ��II -�I+OA /
DIRECTIONS TO SIT ADDRESS tL7—a i,'r•��l
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F1 bt) re--,
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES"' NO g SNOW LOAD:_psf
1S PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW ElADDITION❑ ALTERATION 0 REPAIR❑ OTHER p f)todii low-
USE OF STRUCTURE(Residence,Garage,Commercial Bldg.Erc.) of.eice �p l
pc
IS USE: PRIMARY SEASONAL El NUMBER OF BEDROOMS (JN NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg) YES(Parris]of Bldg)❑) NO❑
DESCRIBE WORK Fite 0`T d- Li/N,/1i o '1tce,c
SQUARE FOOTAGE:(proposed)
1ST FLOOR33 btu 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 sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOORPLAN REQUIRED*
MAKE Ev.e ret s. MODELQUQLti,N YEAR ter / D LENGTHg�y { SIO ►" �/�
WIDTH (20 (++ BEDROOMS VE BATHS a. SERIAL NUMBER 9 1 b - 1 O a 1--LY
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW a EXISTING❑
PLUMBING IN STRUCTURE? YES . NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 Nqgj. 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 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 APPLICATIO 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X Co )p I..1. 1 ViA -i -Z:2_
Signatu e WNE st be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH L/t7.)(/\) .\-(0��