HomeMy WebLinkAboutBLD2023-00040 - BLD CD Environmental Health Review - 1/12/2023 '''c.p' MASON COUNTY COMMUNITY SERVICES Permit No:0L,PRa,W3" 000116
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PERMIT ASSISTANCE CENTER:
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I I 815 W.Alder Street,Shelton,WA 98584 ^� '� tAks
y ` . Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone F1 VV�� �`
�h�oyti= Beffair.(360)275-4467•Phone Elms:(360)482-5269 + '1 2023 k'(�
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BUILDING PERMIT APPLICATION Q� IRON MENTAL
PROPERTY OWNER INFORMATION: CONTRACTOR INFOR ioN'A1d W
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NAME:ille-Ci)4///Aiae NAME H EALZ H
MAILING ADDRESS:/9Oy P4fi,Cs2 /4) MAILING ADDRESS:/9 a9 ,esrN/,j
CITY 4/7 / STATE:M./At ZIP:91s-Sif ' CTTY:S/—//47f STATE:4J,¢ ZIP:Q{<S
PHONE#1: 36U-74/- '77(o PHONE ,a VIP-L /CELL:
PHONE#2: EMAIL: /7 472/,C.X e-1,' - el 67/2rtil,-6" f
EMAIL: _/ -,1 /9y,-&7/OtelC/vf./Di� L&I REG#SeC?5j'Y3-D 2- EXP. 7/2/2 S/
PRIMARY CONTACT: OWNER 0 CONTRACTOR' OTHER 0
NAME c.IC 7 /) i,.C,- EMAIL "97.4.Alki /1oy(0 C�rn4-7'Ie0,-71
MAILING ADDRESS J/SD; /�. -C-,C SDI/ �SDI/ no CITY4:-/74,4/ STATE a/ref, ZIP-' C—
PHONE ?6,0 5/9, - ,71/ CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 7l 9 )/-3/-0622.J ,/ ZONING 1QX j4t'/}�c`S
LEGAL DESCRIPTION(Abbreviated)6 p tJ7 .1)13 L y/N( n/#,/LY R D�/S, CT
SITE ADDRESS Sr- �,/�c�/,4 CII /Y "- /A DIRECTIONS TO SITE ADDRESS /),e74,3,l/6 Scf,(--7-4,‘") u x // /6 7" c'9M./1 ZynlE.�/,f/.1
01.7 Z,?t7z -7J ze, ,C Sr)1 i 1- ,72# b- -f'i.44, `� i/ l it/h,) ffIX L 1
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO 0 SNOW LOAD:-__psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE 0 RIVER/CREEK 0 POND 0 WETLAND 0 SEASONAL RUNOFF 0 STREAM 0
TYPE OF WORK: NEW ot ADDITION 0 ALTERATION 0 REPAIR 0 OTHER 0
USE OF &E STRUCTURE�(Residenoe,Garage,Commercial Bldg,Etc.) �L�S'//)C/if
IS USE: PRIMARY(X SEASONAL 0 NUMBER OF BEDROOMS / NUMBER OF BATHROOMS �
HEATED STRUCTURIE?? YES(Whole Bldg)0 YES(Part/s]of Bldg)0 NO❑
DESCRIBE WORK /1/>r IA/ /q.s'%/? eG'/JS"]/1P-c1t/&.✓0 r" 5%&,74/& /i- a-„t)j /74,77r
SOUARF,FOOTAGE:(prepased) /
1ST FLOOR Y36 sq.ft. 2ND FLOOR ' sq.ft. 3RD FLOOR _ sq.ft. BASEMENT "- sq.ft.
DECK .- sq.R COVERED DECK - sq.ft. STORAGE — sq.ft_ OTHER sq.ft.
GARAGE got) sq.ft. Attached Detached❑ CARPORT goo sq.ft. Attached g Detached 0
MANUFA /2F. TION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MODEL LENGTH
IPTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC IX SEWER 0 / NEW k EXISTING❑
PLUMBING IN STRUCTURE? YES 14 NO 0 If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 / EXISTING SQ.FT.
EXISTING BEDROOMS 0 PROPOSED BEDROOMS I / TOTAL BEDROOMS I
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 THI PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATIO OF 180 D YS OF M . E WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
OUNTY CODE 14.08 2)
Signature of OWNER(Must be signed by the ER) Date
DEPARTMENTAL REVIEW APPRON DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH 4 CiA-4( hA4 RM4
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