HomeMy WebLinkAboutBLD2023-00209 - BLD CD Environmental Health Review - 2/28/2023 Mir.
;`'r' MASON COUNTY COMMUNITY SERVICES Permit No:e au R3- nb 2d o�s-
PERMIT ASSISTANCE CENTER: ep
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL REC Y� ,.....I
615 W.Alder Street,Shelton,WA 98584
„it; r ` 7 .
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone Lim, ,? c(fit` _
�` Beltair(360)275-4467•Phone Elma:(360)482-5269 FEBF �j *�1 `r•�
/�'V�..H11 �t1~ APPLIC 4A.V\Ps�1 F
BUILDING PERMITAlder ` 6 c=
•PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: «Ec'..,
NAME: rk ant i�ae t,s on NAME: IV/4 Cr'
MAILING ADDRESS: q20 f 4ar% fi Ve MAILING ADDRESS: L'
CITY�'nr.``v' Grove, STATE: ( 2 ZIP:9'39S O CITY: STATE: ZIP: LL"
PHONE#1: R 3 I '4 0 2 00 ID PHONE: CELL:
PHONE#2: R 3 i v/3 i...k ki a EMAIL: o
, EMAIL:p c J r,h n s l�n c & n c c 9 1 o b al, q e L&I REG# EXP._/ /_
PRIMARY CONTACT: OWNER 0 CONTRACTOR❑ OTHER
1 NAMES.rn r rqq Sfinn\em EMAIL Ct'a11c�v� � q•
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MAILINGADDRS r7glcP, �L Puc�e''t' kt�-A Lt.) CITYPor� Orn & STATE 1.$)a ZIP �Ifi..3 1
PHONE 'Z(p0 Ff'7i 2f3'.; 3 CELL 3(Dr) `73i 331I
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 2 7_"L72_.2-2L007 D _ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT NJ2 L ciz4-rPik TI
rn
SITE ADDRESS 14io 0\ L''• SA0..�e 1200,1c i0(n CITY RI,,LPatr �f�17 CO nn
DIRECTIONS TO SITE ADDRESS .Sr,uk' ll SbnrE, Ka U it,ck *t•• kiitP n I m ry uuu
C CO
IS THE PROJECT WITHIN 300 Fr OF SLOPE(S)GREATER THAN 14%: YES. NO Si SNOW LOAD:3 0 psf m No
v IS PROPERTY WITHIN 200 F F OF THE FOLLOWING: (Check all that apply). Is,"W
SALTWATER Ill LAKE❑ RIVER/CREEK❑ POND❑ WETLAND 0 SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION l ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence,Garage,Commercial Bldg.Etc) 2-p,cji A ,n c,e
IS USE. PRIMARY❑ SEASONAL® NUMBER OF BEDROOMS ; NUMBER OF BATHROOMS 2.
HEATEDSTRUCTURE? YES(Whole Bldg)® YES(Pan(s)ofBldg)❑ NO❑ e.i-Usp' (:�o v'Wcce, f1
DESCRIBE WORK lJr.,mA.,j(~,enn'k ,°tc&(pi)ri v c i-'Xr.-e.t -I-, t .u,P.r t,k A6,04,1* C
SQUARE FOOTAGE: (proposed) acketas0r
1ST FLOOR.\\Ca.sq.ft. 2ND FLOOR_ sq.ft. 3RD FLOOR TVA sq.ft. BASEMENT 16 sq.ft.
DECK, -31 sq.ft. COVERED DECK 1‘)/14 sq.ft. STORAGESI sq.ft. OTHER / sq.ft.
GARAGE_ Lill_sq.ft. Attached 0 Detached❑ CARPORT ru/A sq.ft. Attached❑ Detached❑
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® SEWER❑ / NEW 0 EXISTING IN
PLUMBING IN STRUCTURE? YES e NO❑ Ifyes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 NOD EXISTING SQ.FT. I i 124
EXISTING BEDROOMS 2 PROPOSED BEDROOMS iSk TOTAL BEDROOMS 2
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) 7 //��
Signaturebf OWNER(Must be signled by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL // J l�
PUBLIC HEALTH _ `II V1('7� _ (tti�li t.tlill Q If'>rl
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