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HomeMy WebLinkAboutGRD2003-00006, RAP - GRD Application - 4/22/2003 /17/00 MON 11:10 FAX 3604278425 MASON COUNTY �002 PERMT � ) �� Mason County Road Department V � 411 North flfth P nt Permit Number: 7J7 P.Q. Box 10 Road Name Shelton, WA 98584 Road Number C% o u Q 1/u r Road Location: 1Oe 06 Subject to all terms, conditions and provision. written or printed below or on any part of this form, Permission Is e l3 a z Hereby Granted To: 7S S A a-- Si To Install: ���� 1 b C G el A C C .� Location: PC 0- Parcel Number: S J CA J •4 - 3 o o Legal Description: N kJ 5 w t `1 tj u S k [Address nd in the amount of $ 2 � — J accompanies this permit, Receipt Number: 17 7 Check N (� umber: ractor :/St/Zi P.v ` xe p"Number: L4 v - 4 q,, Expires; e'Z SpeaifiCations• Access to be graveled to property line with V depth of clean gravel. C Access mil be staked and flagged by Permittee for ulvetT to be aluminum,concrete or polyethylene. Access will be Pre-i a n. Culvert coal lay in line of ditch. 1�•inspaeted by this office prior to installl ation.on. Access installaVon shall be in accordance with county apee�cetions. Cuiv�to be minunum of 12"dl�meter by,�0'length. Canrnerclal/lylultl use access shall require STOP signs,Installed in conformance to the MUTCD manual,at intersection with county road. No work shall be done under this permit until the party to whom it is granted has communicated with and received instructions from the road supervisor at: 360-427-9670 ext. 450. RESULTS OF SITE INSPECTION: See Attachment eAn This permit shall be void and bond forfeited to work herein contemplated shall have been completed County unless the or before: Dated at Shelton, Washington, this _ day of Issued by: Title: MASON COUNTY PERMIT NO.: GRD LAND MODIFICATION PERMIT APPLICATION I. A.10 Shelton 360 427�670 Belfair 360 2775�467 Elmae360 482 5269lton,WA 8Sea APPLICANT INFORMATION Owner CONTRACTOR INFORMATION9sa Mailing Address Contractor Name City State Mailing Address e Phon Zip Code Lien/Title Holder .Ph.( City State Ph. __ Zip Code _ Address Contractor Reg..# �Other Ph.�� ENGINEER INFORMATION Name Address Phone State— _Zip Code PARCEL INFORMATION-12 digit Tax Parcel No. =r :; Legal Description / Site Address(include street name and city / Fire District__ Directions to site: Will timber be cut and sold in parcel preparation? Is your property within 200'of the following: (Yes/No) Lake__ River/Creek Body of Water(Name) BluffsSoft compressible soils_Wetland___Seasonal Runoff Saltwater Stream_ Slopes or TYPE OF JOB -Excavation Size of area to be cleared on slopes ovller 1--- g Grading__ Total size of area Describe Work _. Estimated amount of cubic yards. r LAND MODIFICATION INFORMATION Will fill be brought on site? If yes, source e YES NO Will excavated materials be taken off site. y s �, L--- - � c Does fill contain potential hazardous materials?e , destination �p ❑ Has a soils report been completed on site? ❑ Will proposal result in redirection of any surfaceewaterirudnoff onto adjacent Properties? Will proposed work alter where storm water or ground water enters or exits the site? ❑ Will quality, quantity or velocity of storm/ground water be altered? p pertles? ❑ Will runoff be collect 13 ed/controlled by interceptors, curtain drains or other coil ❑ Will the land be replanted upon completion? Will the proposal result in slopes steeper than those currently on site? collection devices? ❑ ❑ Is the site within 200' of a designated shoreline? © ❑ ❑ ❑ NOTICE: THIS PERMIT BECOMES NULL VOID IF WORK OR CONSTRUCTION AU ❑ CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DgYS qT ANY TIME PROOF OF CONTINUATION OF WORK IS BY MEANS OF q PROGRESS INSPECTION. The owner or agent information provided is accurate and grants employees of Mason County TYS AT D IS NOT COMMENCED WITHIN O DAYS OR ED IF AFTER THE WORK IS COMMENCED. inspection of this project. Acknowledgment of such is by signature untyNaccess to the above described property behalf,represents that the OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of Y and structures for review and the Contractor Registration Law RCW 18.27 and am aware of the ordinance requirements for which this permit is issued and that all work CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a will be done in conformance therewith.permit changes shall d t made without contractor in the State of Washington and that I hi aware of the first obtaining a ordinance requirements regulating the work for which this permit is issued 9 approval. and all wgFk shall be done in conformance therewith. No changes shall X be made:without first obtaining approval. Date X, , FOR OFFICIAL USE BEYOND Date Accepted 4 THIS POINT¢`� l Date .. __r_Submittal Amount Due W , DEPARTMENTAL REVIEW APPROVED DENIED Receipt No. ' Building Department CONDITION CODES Planning Department Public Works Department Sly o Fire Marshal Grading Permit Fee FEES Plan Review Fee Site Inspection Public Works Fee Other Violation Fee Pre-Paid at Submittal TOTALFEES ( ) PERMIT No.: GRID COUNTY LAND MODIFICATION PERMIT APPLICATION 0DXp 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968 FFAPPLICANT`-1wrxIvI/A ITION T;"� CONTRACTOR INFORMATION ddress Contractor Name State Mailing Address Zip Code---�—___Other Ph.�� —' City State Zip Code Lien/Title Holder ---- Ph.(�l�_Other Ph.(. —'--- Address Contractor Reg. # Expiration / / ENGINEER INFORMATION Name Address Phone (�) State �Zip Code PARCEL INFORMATION-12 digit Tax Parcel No. 11 a 1 Legal Description / / Site Address(include street name and city Fire District__ Directions to site: Will timber be cut and Sold in parcel preparation? Y Is your property within 200' of the following: Body of Water Lake River/Creek Pond Bluffs Soft compressible soilsWetland__SeasonaI Runoff Saltwater Stream Slopes or TYPE OF JOB -Excavation_ slopes ovler 1g0��o Grading__ Total size of a Size of area to be cleared on rea "" Describe Work �'t Fl c 6 � ���'I,3 0 , Estimated amount of cubic yards ooTl r� D A LAND MODIFICATION INFORMATION Will fill be brought on site? If yes, source 2UfQ YES NO - Will excavated materials be taken off site? destination© l�IZv.TC tT Does fill contain potential hazardous materials?es, destination a ❑ Has a soils report been completed on site? ®copy. CI Will proposal result in redirection of any surface ewaterlrudnoff onto adjacent properties? ❑ ❑ Will proposed work alter where storm water or ground water enters or exits the site? ❑ 13 Will quality, quantity or velocity of storm/ground water be altered? 13 Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? ❑ ❑ Will the land be replanted upon completion? Will the proposal result in slopes steeper than those currently on site? ® ❑ Is the site within 200' of a designated shoreline? ❑ ❑ NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENC PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behlf,represents that IF information provided is accurate and grants employees of Mason County access to the above described property and structures for review D inspection of this project. Acknowledgment of such is by signature below: hat the and OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the Contractor Registration Law RCW 18.27 and am aware of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a ordinance requirements for which this permit is issued and that all work will be done in conformance therewith. No changes shall be made without contractor the State of Washington and that I hi aware of the ordinance requirements regulating the work for which this permit is issued first obtaining approval. and all work shall be done in conformance therewith. No changes shall X be made without first obtai ng approval. Date X FOR OFF CIAL USE BEYOND THIS POIN Date Accepted b YV—LqL—Dat bmittal Amount Due Receipt N DEPARTMENTAL REVIEW APPROVED DENIED Building Department CONDITION CODES Planning Department �d � A Public Works Department Fire Marshal Grading Permit Fee FEES Site Inspection Plan Review Fee 1/7 Public Works Fee Other Violation Fee Pre-Paid at Submittal � TOTALFEES