HomeMy WebLinkAboutBLD2022-01395 - BLD CD Environmental Health Review - 10/31/2022[ ,:::-. `''?iip1. MASON COUNTY COMMUNITY SERVICES Permit No:13Id2022 -oi3e/5
c" PERMIT ASSISTANCE R
•BUILERDING•PLANNING•PUBLICCENTE HEAL:
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TH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584 `"-'_r
%r f < Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone 1 \ f t III���
Belfair(360)275-4467•Phone Elma:(360)482-5269 \\\ \ /�,1 ,
BUILDING PERMIT APPLICATION O`r� V V
PROPERTY OWNER INFORMATION:O CONTRACTOR INFORMATION:
3" Ev( ���Z
NAME: F1 6 _._ NAME: �IQI
MAIL A D ES: (od I (�tL MAILING ADDRESS: C9r S
CITY: &t r'4 t�a STATE: VZIP:`TegV'P'CITY: STATE: ZIP: Iteet
PHONE#1?,(v0 d..7 5-a PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: L&I REG# EXP._/_/
PRIMA CONTA T. , OWNER CONTRACTOR 0 OTHER 0
NAME C�� V As''' -' EMAIL
MAILING ADDRESS — — CITY STATE ` ZIP
PHONE CELL /`�_ /I
PARCEL INFORMATION: as 0 l �� 3— Ubb .�U V49
PARCEL NUMBER(12 Digit Number) ZONING N/�w
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT F,q j r�Y��/I���
SITE ADDRESS !L I IJ C 1 C K, CITY [ , �/
DIRECTIONS TO SITE ADDRESS /7
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES NO 12( SNOW LOAD:Rbpsf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE❑ RIVER/CREEK❑ POND 0 WETLAND 0 SEASONAL RUNOFF 0 STREAM 0
TYPE OF WORK: NEW®' ADDITION❑ ALTERATION 0 REPAIR❑ OTHER 0
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) - l e
IS USE: PRIMARY❑ SEASONAL 0 NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES YES(Whole Bldg)0 YES(Parrts]ofBldg)❑ NO-®
DESCRIBE WORK 1'.+ Del CrL & UC /ectiQ.)
SOUARE FOOTAGE: (proposed)
1ST FLOOR_ 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 00 _ i ft. Attached 0 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 SEWER / NEW 0 EXISTING
PLUMBING IN STRUCTURE? YES NO If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 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 7—8--7 --
Signature o WNER( ust be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL p
PUBLIC HEALTH ' ki0, � C,�'�E - \ 0 d 0..'"'
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