HomeMy WebLinkAboutBLD2023-00158 - BLD CD Environmental Health Review - 3/9/2023rill"."1111.8.11*. "P -ox C.Kr4ry MASON
PERMIT COUNTY ASSISTANCE COMMUNITY SERVICES (�) V
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t •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL I NI
ji615 W.Alder Street.Shelton,WA 98584
�/ Phone Shelon:(360)427-9670 ext.352•Fax:(360)427-7798 Phone MAR 0 0 2023 ����
Bellafr.•(360)275 d46�•Phony Elmo:(360)4825269 /V
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BUILDING PERMIT APPLICATION RECEIVED FEB
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: -6/4,,
/S In, v 6 ��23
NAME:C 116 S ii,lciv,h L NAME:A$L J a;/CI, I C.o vi llcc/c>rf • q/der
MAILING ADDRESS:2t170 . /)I;,'/r,S L./'c.Loc./4) ADDRESS:/ .130Y 7 -/3 si
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CITY:_5j1�•f%G11 STATE: l/l//4 ZTP:Qk 5 9/Qd CITY: e 'r STATE: L✓/4ZIP: 9e5 2,-j-
PHONE#I: 253 " 2 914 -ff7,5(; PHONE: CELL:360-r) ,/-/(//t/
PHONE#2: EMAIL:
EMAIL: L&T REG 4/4 L/3 U1 e61 3//i/ EXP.,5 /2./123
PRIMARY CONTACT: OWNER❑ CONTRACTOR X OTHER❑
NAME /-1L Carc/c'1 St EMAIL
MAILING ADDRESS / D. 1 - 23'/3 CITY 73e/rc,/r STATE 1./i.-'/g-ZIP I'52:5-
PHONE CELL
PARCEL INFORMATION: k/�f tVi
PARCEL NUMBER(12 Digit Number) 2 UG 55(+0 0 0 .:j 0 ZONING , y R4A1 AA
(Abbreviated) FIRE DISTRICT l FNT
LEGAL DESCRIPTION Abbreviated 1 /e,,C/tE 11 __� w
SITE ADDRESS Z170 h!/Iris• L/(. !(rLt° l�t‘ CITYS1 0//CI Cr' At
DIRECTIONS TO SITE ADDRESS ry
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YEW NOA ?
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check a!!that apply,:
SALTWATER❑ LAKE RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(P,,idercr.Garage.Commercial Bldg,Etd) ( 6‘f C.,1 e
IS USE: PRIMARY❑ SEASONAL IX NUMBER OF BEDROOMS () NUMBER OF BATHROOMS C
HEATED STRUCTURE? YES(117rore 81dg)❑ YES(Purt/s/of Bldg)❑ NO 4,
DESCRIBE WORK
SQUARE FOOTAGE:(nrupose+ctirhag)
1ST FLOOR"3 i / sq.ft. 2ND FLOOR -/ 7 5 sq.IL 3RD FLOOR D sq.ft. BASEMENT sq.It.
DECK /Y/e- sq.ft. COVERED DECK ft/I. sq.ft. STORAGE /Yh sq.It OTHER sq.ft.
GARAGE 2-0 1{3 sq.ft Attached❑ Detached❑ CARPORT /y 4- 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: SEPTIC2r SEWER❑ / NEW❑ EXISTING,K
PLUMBING IN STRUCTURE? YES❑ NO rf\ If_yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES ( NOD EXISTING SQ.FT.
EXISTING BEDROOMS NA PROPOSED BEDROOMS /V/4• TOTAL BEDROOMS_ VA
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)
Xi-t_ �C>1..,-Y krf - 1 2 1 -7 - 7
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 ,,�,�J
PUBLIC HEALTH Vft 100/13 adate
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SHELTON,WA 98584 SHELTON,WA 98584 .flllj!l 9