HomeMy WebLinkAboutBLD2023-00126 - BLD CD Environmental Health Review - 3/31/2023 nM:t MASON COUNTY COMMUNITY SERVICES Permit No: 6)LQ20o23-- �l(36
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PERMIT ASSISTANCE CENTER: t" "" +k s_
I•BUILDING.PLANNING•PUBLIC HEALTH•FIRE MARSHAL I \i.._L ,t V f�...,,
I= •I 't 615 W.Alder Street,Shelton,WA 98584 1
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t �J ;q Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone JAN 3 1 2021
O ^yv Be/fair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICA130.N. Alder Street- ,
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
tN\ dRONMENTf'1L
NAME: AUSLiin. 6t e.re, c7" NAME: ,AV541✓l bt^2fC- v\ H EA LT H
MAILING ADDRESS: Z5;4 F}WY 10 MAILING ADDRESS:
CITY: Pod vo STATE: ZIP: q' • . CITY: STATE: ZIP:
PHONE#1: 501 '5D -I43&4/ PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: a b re-r eAo rl Fj(Qa't 661 e1 i l,(AM L&I REG# EXP. / /
PRIMAIIY CONTACT: i OWNER S CONTRACTOR❑ L OTH ❑
NAME AUS+./1 b(ere-tax , EMAIL aOf-re '14,7 b?I4�,.rl,( 131
MAILING ADDRESS "-`J,-3'b(. V 171Y 101 CJTY doe r STATE A ZIP el4,5 IfS'
PHONE CELL 10( 0110 -7S5
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) e Z 2 o/y 3oov u ZONING R12 5
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS CITY
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES® NO 0 SNOW LOAD:21psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE 0 RIVER/CREEK❑ POND 0 WETLAND 0 SEASONAL RUNOFF D STREAM❑
TYPE OF WORK: NEW Dr ADDITION❑ ALTERATION�f 0 REPAIR❑ OTHER 0
USE OF STRUCTURE(Residence.Garage,Commercial Bldg.Etc.) kes;Ail c-. .
IS USE: PRIMARY® SEASONAL 0 NUMBER OF BEDROOMS 2 NUMBER OF BATHROOMS Z
HEATED STRUCTURE? YES(Whole Bldg)0 YES(Pan )of Bldg)E2 NO❑
DESCRIBE WORK N(2.,Ul '1 (J R6t,'IiJ 116Me
SQUARE FOOTAGE:(proposed) �J
1ST FLOOR sq.ft. 2ND FLOOR 1 t?I N sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER 1 i sq.It
GARAGE q,i3 sq.ft. Attached NI Detached 0 CARPORT sq.ft. Attached 0 Detached 0
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 g SEWER❑ / NEW g EXISTING 0
PLUMBING IN STRUCTURE? YES{gi NO 0 If yes,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 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 TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X G y �� � /- -Z 6 - 202,3
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 r art >, {
PUBLIC HEALTH �i1,J 0q 17k 7ez% e7alf�f t ens of 'e('
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