HomeMy WebLinkAboutBLD2023-00355 - BLD CD Environmental Health Review - 4/3/2023 rsoN cet,Nr MASON COUNTY COMMUNITY SERVICES L .', C D
�� > PERMIT ASSISTANCE CENTER: Permit No: ._ ' .
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
( :iiir 615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone APR 0 3 2023
Belhaic(360)275-4467•Phone Elms:(360)482-5269
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BUILDING PERMIT APPLICATION 615 i . • der St eet
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
M �
NAE:f(NN( .�+4fri U I I�Ct G 1i NAME: K(.I L I SC.,L1 chi b ct C li P ��
MAILING ADDRESS: 26 7 3 E t4 ti , 1.1( OL E MAILING ADDRESS:26 7 3 6 M e^ ot. L Z i?• _
CITY:C41.ap o V)p w STATE:WA ZIP:q&si- CITY6t-yroL I 0 w STATE:\ 14 ZIP: ` N ."• r
PHONE#1: 3,4 O 47 3` 7 42.4- PHONE:36r,s-45-I OO CELL: 36c 4'73- t Z i
PHONE#2: 60 345- (Oot EMAIL: KA RA_14. 47 e I.IV<,C.c, - c' C
EMAIL: I(/�PIL,1,4 4-7 Q. L I U C • C.oM L&I REG# EXP. /_
PRIMARY CONTACT: OWNER ailCONTRACTOR❑ OTHER❑
NAME I-4,^I ``tiu(VC!(Jet EMAIL 1CCCN114. 4-70 Lit)6. C6 . T0-
MAILING ADDRESS 167 3 C Mtitr, Llt. Qt.. E CITY (16^e-tpovi'cw STATE W� ZIP fee D Z
PHONE .340 %7j - 14;1-4- CELL ELI 7!
PARCEL INFORMATION: = r
PARCEL NUMBER(I 2 Digit Number) 2'2 2.93 52 490047
00.S 7 ZONING R u eji Res 611;A I Z
LEGAL DESCRIPTION(Abbreviated) Lot 57 c-S g MA 1 rt.4/ ,SIi nt^it a FIRE DISTRICT .ice
SITE ADDRESS'j 3 C M 1.i,£�� L I, p t' [ ✓ CITY Cell/p 0 Via a W r
DIRECTIONS TO SITE ADDRESS r�� 3 ft, M 40 p.•r 13,2, f to ci , i-i`.,I + or,
_E Mctf,?•, llL Dk- C 4b 14adeQ..% 0.,‘ left - tf
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO XI
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE rgi RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW® ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) C)(yl^6I i P
IS USE: PRIMARY RI SEASONAL❑ NUMBER OF BEDROOMS 0 NUMBER OF BATHROOMS C
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Parr[s)ofBldg)❑ NO
DESCRIBE WORK
SQUARE FOOTAGE:(propose+existing)
1ST FLOOR ... .. sq.ft. 2ND FLOOR — sq.ft. 3RD FLOOR sq.ft BASEMENT sq.ft.
DECK sq.ft. COVERED DECK — sq.ft. STORAGE r sq.ft. OTHER — sq.ft.
GARAGE p 64- sq.ft. Attached❑ Detached tgl CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE N/A MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ail SEWER❑ / NEW❑ EXISTING X
PLUMBING IN STRUCTURE? YES❑ NO DR If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YESfij NO❑ EXISTING SQ.FT. 864-
EXISTING BEDROOMS 0 PROPOSED BEDROOMS 0 TOTAL BEDROOMS O
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 commerced within 180
y
7 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)
Sure of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
-
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH 2 sllbh7> C u•d- lt,V1,S q
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