HomeMy WebLinkAboutBLD2022-01114 - BLD CD Environmental Health Review - 8/22/2022 sP'-ik MASON COUNTY COMMUNITY SERVICES Permit No:DLO .O aa"a 1 11 ti
o PERMIT ASSISTANCE CENTER:
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w1.1 •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHIRECEIVED ,/1 0 , 1
1 k 615 W.Alder Street,Shelton,WA 98584• �:r
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Z1 Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Pho
9 C ��;�?p N M E N TAL
Beltair. (360)275-4467•Phone Elma:(360)482-5269
`"�•}flira�� 615 W. Alder Street HEALTH
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: Co r_ . ll NAME: gi ll A C�Tu Ulna 1
MAILING A RESS: 41t 6 1 sor``- CT C MAILING ADDRESS: Qo IYoX �.o y�
CITY: Qkry11w' STATE: \.� ZIP: 4 8371 CITY: O\�►-►Qi Q STATE•� l�� ZIP: 9�So�
PHONE#1: D S 3.y q c- 9 d'-I PHONE: 3 Co_a 0 3 $CEI L:
PHONE#2: EMAIL : 0 t 11 AC. ltac vta Q o?-+�'►I. L"'''
EMAIL: Cm r� Caw�nc lLQ�M�;1,co►^i L&I REG # G 4 g, 3 3 s-o 0 EXP._/ /
PRIMARY CONTACT: OWNER ig CONTRACTOR 0 OTHER❑
NAME `or O�vAcll EMAIL Lor�cCar.-Ke_AI Qj-h01). (.oil
MAILING ADORESS 11 6 1so" ST E CITY Qv 1\y f STATE (-IA ZIP'g37 r
PHONE a,lj 3-495-- 3404 CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 3 7-G?-1 - c 3 " 0 3 o n 5 ZONING C eS d t±„t'a 1
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS .P4) CAS S'.ere- c,reSi- ' ' - CITY S' \.%o►'\
DIRECTIONS TO SITE ADDRESS S (), 3 ,I; o.. C pga}-L 34 to E. (,r,S rtI i et—) Of w►.(Ok
btt06.4) a 9.,orecres} or .T1+c. ee(cc1 iS Gi„Qrok 1- eldle-J eAS4' 04 aovnt•,-,•v Stvel'l°K •
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YESK NO ❑ SNOW LOAD:3 0 psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE❑ RIVER/CREEK❑ POND 0 WETLAND ❑ SEASONAL RUNOFF 0 STREAM ❑
TYPE OF WORK: NEW ADDITION ❑ ALTERATION ❑ REPAIR 0 OTHER ❑
USE OF STRUCTURE (Residence,Garage,Commercial Bldg,Etc.) C`es t a Ct^cc-
IS USE: PRIMARY 1 SEASONAL 0 NUMBER OF BEDROOMS 3 NUMBER OF BATIIROOMS
HEATED STRUCTURE? YES(Whole Bldg) NJ YES(Par/ o.0/dg) 0 NO 0
DESCRIBE WORK ,N cortStrthc-P'0 ' • K.Std-1l /4ewu. c-4-.reil` Ho sit
SQUARE FOOTAGE: (proposed)
1ST FLOOR\a q 6 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 0 Detached 0 CARPORT sq. ft. .4ttached❑ Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE eG\M. 1- 1,
kar1of 4
MODEL 9Q Scg
Soy YEAR 203 LENGTH yS
WIDTH 2.71 BEDROOMS 3 BATHS a SERIAL NUMBER QNi 11 -31 o R 22.- 15104 B
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW til EXISTING 0
PLUMBING IN STRUCTURE? YES RI NO❑ If yes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? Y E S 4 NOD EXISTING SQ.FT. 0
EXISTING BEDROOMS 0 PROPOSED BEDROOMS '3 TOTAL BEDROOMS 3
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
ranracpntativp rpnrespntc that tha infnrmat inn nrnviripri do arnnratp and nrantc pmntnvnpc of Macnn Rnnnty arracc to tha ahnvp ripcnrihpri nrnnrrrty
oorainea permission rrom at 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 nut&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
PEy APPLICATION OF AYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL /, ,�
PUBLIC HEALTH ZIL3}.3 C-`' 4 -YIALi cci eA
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