HomeMy WebLinkAboutBLD2021-00946 - BLD CD Environmental Health Review - 6/17/2021 • �lynx oou, MASON COUNTY COMMUNITY SERVICES 6 L oz 2 •, 00? 9(J/
/1A�j PERMIT ASSISTANCE CENTER: Permit No: V ( �lll//
3 `) •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL !R 0 N tii N TA L
r 615 W.Alder Street,Shelton,WA 98584
NZ Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone HEALTH
Bellair(360)275-4467•Phone Elma:(360)482-5269
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BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: R E C L `tf „y
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NAME:4e1111 eI NAME: &JAW,/ ill I p,�,
MAILING ADDRESS:Ha 'kt� VI E. ( 4-2 I MAILING ADDRESS: >> •
:=• 1 F LU-•1
CITY:A Mourn STATE:i, l :t1 f0 a 2 CITY: STATE: ZIP:
PHONE#1: .l, .2.1V I PHONE: CELL: 615V11. I;iC r Street
PHONE#2:tJ "L EMAIL:
EMAIL:`I1�hn0'fL," C .Yet:i L&I REG# EXP._/_/_
PRIMARY CONTACTT: OWNER% CONTRACTOR❑ OTHER❑
NAME 64.11,0 !q (i bbifi EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) if 2.1. I260 I I D I Z ZONING R\• , • V
LEGAL DESCRIPTION(Abbreviated FIRE DISTRICT
SITE ADDRESS I Vt ti• f lY1(,�l (;reek e6t• CITY �Opds brf
IRECTIONS TO SITE DRESS 1 (1,1 t -}6 t fwt Lr�� ccry 11d,VI1I710. E.YL�)
louse is m rnikt- 0 eau e-ed roi bends
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check al that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK 1K POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION❑ REPAIR OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) Sunmyke.r rem denCl," 1 atikti m
IS USE: PRIMARY❑ SEASONAL' I NUMBER OF BEDROOMS Z NUMBER OF BATHROOMS I
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Perils]of Bldg)❑ NO❑
DESCRIBE WORK1t'k&t(T( J�k'rum.krl re-wt(e1 re-�11�,1v6� re no ell iris tt1C'
SQUARE FOOTAGE: (propose+existing)
1ST FLOOR//,^ L1., sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR 0 sq.ft. BASEMENT 0sq.ft.
DECK RI W 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: oIP *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC® SEWER❑ / NEW❑ EXISTING kl
PLUMBING IN STRUCTURE? YES® NO❑ If yes.attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOD EXISTING SQ.FT.
EXISTING BEDROOMS Z PROPOSED BEDROOMS 2. TOTAL BEDROOMS Z
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 APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION O BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X - aoa
Signa f OWNER(Must be signed by the OWNER) Date
DEPARTMENTA,REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL j,� � ,��
PUBLIC HEALTH CZ-CT V�'�71i 1 C-Cr 1 ( 1.7\.S Q��,y&`vs'
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