HomeMy WebLinkAboutBLD2022-01416 - BLD CD Environmental Health Review - 11/3/2022 ' - MASON COUNTY COMMUNITY SERVICES . Permit S�V Oa _D I
PERMIT ASSISTANCE CENTER: ' '*' ' -" [�, Np�i II pp N M E L
l`' 7 MA
.BUILDING•PLANNING•PUBLIC HEALTH•FIRE RSHAL 1
11• 615 W.Alder Street,Shelton,WA 98584 pt(�\Y - 3 e0l) HEALTH
f' •� Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 ne Belfair(360)275-4467•Phone Elmo:(360)482-5269 pp } i�l 1�
BUILDING PERMIT APPStICATr 12xlep,,-\as(v\cvs\_1,c, ‘'\/\
Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:�C.Ob 2J LA ' A . ll 6 I. NAME: RZ`.�0,n \I f it-MAILING ADDRESS: . ", A..a ,- . 4,' . MAILING ADDRESS:
CITY: he_I-ton STATE: I,UA ZIP: ' Z..Zk1 CITY: STATE: ZIP:
PHONE#1:?IjO- LfqU - 3Le(pC) PHONE: --_ —CELL?(,-C c,CC Ci((F"
PHONE#2: EMAIL:
EMAIL:AA s.• to e. AI O. II L&I REG 4 EXP._/ /
PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER❑
NAME EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL •
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 1 o' OO(_°3 not a,002- ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS 43S E- A 106t IGt. t4 C(Q2.k �ZcI CITY Sine I-tc.,,
DIRECTIONS TO SITE ADDRESS
IS TIIE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES NO❑ SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all thee apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND 0 WETLAND❑ SEASONAL RUNOFF❑ STREAM 0
TYPE OF WORK: NEW. ADDITION❑ ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence.Garage,Commercial Bldg,Etc)
IS USE: PRIMARY x SEASONAL❑ NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS Ol
HEATED STRUCTURE?,,II YES(Whole Bldg)❑ YES(Parris]of BldglX NO 0
DESCRIBE WORK ht UL) I/IOU X bLu Id
SQUARE FOOTAGE:(proposed) ,•
1ST FLOOR ► U) sq.ft. 2ND FLOOR MIA_sq.ft. 3RD FLOOR NIA sq.ft. BASEMENT NIA sq.ft.
DECK NJA sq.ft. COVERED DECK 19, .sq.ft. STORAGE NIA sq.ft. OTHER PIA sq.ft.
GARAGE 415 sq.ft. Attached Detached❑ CARPORT N.)IA sq.ft. Attached❑ Detached 0
MANUFACTURED HOME INFORMATION: - tl *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL A) A YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER 0 / NEW IA EXISTING❑
PLUMBING IN STRUCTURE? YES IX NO❑ If ,attach completed Water Adequacy Form
PERIMETER/FOUNDATION D 'S PROPOSED? YES NC EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS 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
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 160 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
C i LINTY CODE 14.08.42)
X l.1 -s = -��� �l .� I0/1(; /J-` -
Signature of OWNER(MGst be signed by the OWNER) ! Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL PUBLIC HEALTH Q-. 1
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