HomeMy WebLinkAboutBLD2022-01454 - BLD CD Environmental Health Review - 11/14/2022 (j ' ( Eµ: lsr�b
'''I � E) C -1L�t MASON COUNTY COMMUNITY SERVICES Permit No: ?IO22 `
PERMIT ASSISTANCE CENTER:
•i- •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
•11. 615 W.Alder Street,Shelton,WA 98584
:iw.,r. Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
�yty� y• Belfair.(360)275-4467•Phone Elm:(360)482-5269
14?
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: A\ti1-k. t(;vl A-?-v i NAME:
MAILING ADDRESS:73o 41)4(I i tr' MAILING ADDRESS:
CITY: 51eiJr''. STATE:Lis'A— ZIP:c1 S4St.1, CITY: STATE: ZIP:
PHONE#1: (-5()--y 1 1—'(GZ`':'J PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: 1 I' tC 01" CI L-I M1.41`2EGQ.`' Lr EXP. / /
PRIMARY CONTACT: OWNER E CONTRACTOR❑ OTHER❑
NAME ellr �1-�' EMAIL
PHONE MAILING��fDRESS'`! I — J , ''f I` r t'C714 4) _ CITY S lei I STATE L t-'tT ZIP 9 c S t
1 ENVIRONMENTAL
PARCEL INFORMATION: 7�
PARCEL NUMBER(12 Digit Number) I Cj U v6/O�ri ZONING HEALTH
LEGAL DESCRIPTIQN,(Abbr viated FIRE DISTRICT
SITE ADDRESS b c6 L I IQ V I "\ CITY
DIRECTIONS.TO SITE ADDRESS
IS THE PROJECT WITIIIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO IR SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all Aar apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND 0 WETLAND l} SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW IN ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Esc)
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS Z NUMBER OF BATHROOMS Z
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Part!s]of Bldg.)❑ NO❑
DESCRIBE WORK
SQUARE FOOTAGE:(proposed) Q
1ST FLOOR et30 sq.ft. 2ND FLOOR p 122.• sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK H7(0 sq.ft. COVERED DECK 70 _sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE'S-- sq.ft. Attached❑ Detached 0 CARPORT sq.ft. Attached 0 Detached
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 is SEWER 0 / NEW EXISTING 0
PLUMBING IN STRUCTURE? YES NO 0 lj es,attach completed Water Adequacy 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 proposec.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 APPLIC TION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
Signatur TOWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL nn I /,
4 PUBLIC HEALTH OOP �S F6673 ( ('1 ( '1 ftp15 I?t�G6Lt
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APPROVER
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50'X50' a AEI"
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Printed From Mason County DMS
Printed from Mason County DMS