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HomeMy WebLinkAboutBLD2023-00227 - BLD CD Environmental Health Review - 2/28/2023 i-Ii ps://fnasoncountywa.yov/forms/Cummuniiy_Devjuld_pe rnit_packet.pclf 2/7/23, 11:21 AM - ►A?2) 3622; 1-'`'�` MASON COUNTY COMMUNITY SERVICES Permit No: if R PERMIT ASSISTANCE CENTER: /' '.•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL C .T. V '-7 615 W.Alder Street,Shelton,WA 9858d • Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone D \.' Beltair(360)275-4467•Phone Elma:(360)482.5269 l� \^F / BUILDING PERMIT APPLICATION 6/$ Fes Z8 �Q23 PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: /der NAME: A5 LPr- 6u 1 i cke,r S lam.C.. NAME: As c,eb\ au:(<lee)' LL.'• 10 tre MAILING ADDRESS:-?O(3 `1 V MAILING ADDRESS: et CI-IY:Q;)( ' Ct 4C(-STATE: L,.P• ZIP:c'►'IG.4• CITY: . c„v,.Q STATE: ZIP: PHONE#I:3(b.-Li'.S • 5$1,r PHONE: \CELL: m PHONE#2: NA EMAIL: n EMAIL:CIS Le.,-f to,...,.1 der s 1l c e.1.�41 e�z+.., L&I REG# EXP._/_/ M Lit PRF\LU:Y CONTACT: OWNER❑ CONTRACTOR OTHER❑ l m N NAME T'Ot'•^ cJ,s.1'n}ef� EMAIL 0%5c-en V A-lo r l d }er5 (..ee"l rvv%,t.ta..n 17 coMAILINGADDRESS PC'?) L2.-'? CITY eatI €t,W 4 STATE Lf. ZIP ote3(c v PHONE 414.. CELL Z(.0 --Z(..5- 5gC..2 PARCEL❑✓FORMATION: `N, PARCEL NUMBER(12 Digit Number) 2 Z Z l e S ec 7 Ca/ ZONING t LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT ' I I A� SITE ADDRESS (Q ti �, U l(i n (or cn IK P L CITY at't c5 r DIRECTIONS TO SITE ADDRESS_ 4C)-� '-1 IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO Liz SNOW LOAD:__psf ` IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check att that apply): SALTWATFR❑ LAKF.❑ RIVFR'CRI'EI;❑ POND❑ WFTLANT)❑ SEASONAL RUNOFF❑ STREAM❑ TYPE OF WORK: NEW 0 ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence,Garage,Commercial Bldg.Etc.) S if IS USE: PRIMARY VI SEASONAL❑ NUMBER OF BEDROOMS . ) NUMBER OF BATHROOMS Z.S HEAL LI)STRUCTURE? YES(Whole Bldg) YES(Pan(s)of Bldg)❑ NO❑ DESCRIBE WORK SQUARE FOOTAGE:,(propound) c{u 1ST FLOOR 1 ii9 sq.ft. 2ND FLOOR V l y sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft. DECK sq.ft COVERED DECK Clip sq.ft. STORAGE _ sq.ft. OTHER sq.ft. GARAGE L-I t}(' sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑ -r MANUFAcTL?RF.D NQMF.TNFORMATION: I'1JA*4 COPIES OF THE FLOOR PLAN REnitIRED* MAKE MODEL YEAR LENGTH WIDTH BEDROOMS BATHS SERIAL NUMBER ENVIRONMENTAL HEALTH: 5 0 j 202 2 —(-)00 C. Ai Pgi07 .OV 12- - SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW k EXISTING❑ PLUMBING[N STRUCTURE? YES E NO❑ If yes,attach completed Water Adequacy Form PERIMETER/FOUNDATION DRAINS PROPOSED? YES Vr, NOD EXISTING SQ.FT. C) EXISTING BEDROOMS PROPOSED BEDROOMS .3 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 inducing any easement holder or parties of interest regarding this project. The owner o-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 perrnivapplication becomes null&void it work or authorized construction is not commenced vnthin 163 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 PERM APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON COUNTY CODE 14.08.42) vt x VI, - ' Li - 2-22 ,nenlre of OWNER n/,tnt he q41_1 _hY the OWNER) Date DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT _ FIRE MARSHAL r 2 PUBLIC HEALTH V 5)13,2 .T lam`" ,a' `4 https://masoncountywa.gov/forms/Community_Dev/bld_permit_packet.pdf 4 ---' - • _. 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