HomeMy WebLinkAboutCOM2022-00105 - COM CD Environmental Health Review - 12/27/2022 (2) c�p -' MASON COUNTY COMMUNITY SERVICES Permit No: ?(I ::../ -• 1 .t t') r
C. PERMIT ASSISTANCE CENTER: R 1
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL 1 \ t .. • .--
if 41, . + `yt. 615 W.Alder Street.Shelton,WA 98584 �(//►�
t '` Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone D L t'(1�T7 �>�•f�o�� • ,
•y ,..1�1 Belfair(360)275-4467•Phone Elma:(360)482-5269 L CO t( vL i'� P
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BUILDING PERMIT APPLICATION 3
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: _ - E I V
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C Z 7 ZL
NAME/ uttA CAV fire OIL1 #S NAME:
MAILIN ADpRESS: �76Q)( 19 10 MAILING ADDRESS:
CITY:$1PJ'/ STATE(xi A ZIP:9 QSP9 CITY: STATE: ZIP:
PHONE#1: 340- 44-5533 PHONE: CELL: W PHONE#2: 3bo as 875o EEMAIL: : 13 Alder Street
EMAIL: a.Zi elY� G/iI FP.. OT} L&I REG# EXP._/ /
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER IR,
NAME -11JS+11A -71)(el"e1✓ EMAIL ,p,/�e/IerPCit .CPI'
MAILING ADDRESS Petk 7 1110 CITYSAP/hik r STATE(,s)19 ZIP SBQ
PHONE 3L6- gL-5.c 3 CELL 3L0-?..1Q -S)j0
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) a a j 33 ieR i0 C o.o ZONING f S
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS t CITY (+OA W
DIRECTIONS TO SITT ADDRESS I
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO g SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE 0 RIVER/CREEK 0 POND❑ WETLAND 0 SEASONAL RUNOFF❑ STREAM 0
TYPE OF WORK: NEW❑ ADDITION 0 ALTERATION❑ REPAIR 0 OTHER $/NtOdtI
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) Cfei'C•e
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS () NUMBER OF BATHROOMS a
HEATED STRUCTURE? YES(Whole Bldg) YES(Pants)of Bldg)0 NO 0
DESCRIBE WORK Fl P( �� dAt,l� oP1 c,
SQUARE FOOTAGE:(proposed)
1ST FLOOR33 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❑
MANUFACTURED HOME INFORMATION:� *4 COPIES OF THE FLOORPLAN REQUIRED*
MAKE Evter�rt� MODEL( (kJ(C YEAR Icily QLgENGTH{ 5(0 n --�/�
WIDTH (00 v BEDROOMS BATHS a SERIAL NUMBER / ( " 10& A--.CJr
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW S EXISTING❑
PLUMBING LN STRUCTURE? YES . NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NqIR 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 proposes.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 9/1/�-2- • Cal„pitted la -2 -2,2_
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 HEALTHjriji/J V-((I