HomeMy WebLinkAboutBLD2023-00336 - BLD CD Environmental Health Review - 3/27/2023i
�eos couy MASON COUNTY COMMUNITY SERVICES t ,( 3 2
�° '} PERMIT ASSISTANCE CENTER: Permit No: L- Ic-'1 2de -00 3i3L
� � •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
` ,- 615 W.Alder Street,Shelton,WA 98584 RECEIVED
"" -- y_ Phone She/ton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
Belfair(360)275-4467•Phone Elma:(360)482-5269
W./ MAR 2 7 2023
BUILDING PERMIT APPLICATION }} /�/ m z
PROPERTY OWNER INFORMATION: CONTRACTOR INFOR ATIO�1:' A�CJ t✓I Slit t et < r— u�;
Can
D_ y \Id/.)l.'1 C'o. ,� o N
NAME: Ic;nclvt/�� „ �� NAME: Jrcic
MAILING ADDRESS: Po i. I c; 11 MAILING ADDRESS: I'D rjta,( I I\61 c.)
CITY:iRrlt ... STATE:\Allp ZIP:7 c '() CITY: ,-.1-�,:ti STATE:I,t,'L� ZIP:67'r);2t-. rn
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PHONE#1: (0 1 77-7-r') PHONE: CELL:}(C '7. 1--7)0 I
PHONE#2: EMAIL: JJc L . . vie r
EMAIL: ` C, he-r L&I REG# ,).;G,K J C , /;i.Z/N\EXP. 3 /?//202�}
I' = X
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑ m O
• NAME EMAIL
MAILING ADDRESS CITY STATE ZIP Z
PHONE CELL ili
PARCEL INFORMATION: = Z
7_
PARCEL NUMBER(12 Digit Number) ZZ7 J - J G�G(J� , C/ O;TING 2 c:,, e.1741 r� ( _
LEGAL DESCRIPTION(Abbreviated) itiL1) 5ey y>•IT)v jt-,.,,-1-$ ) C'i IlC,a N---PitE DISTRICT '2-- >
SITE ADDRESS 11 y 51 67. S;., p0,,4.? /D 6 CITY r P I ,v" 4/Y-2!' r
DIRECTIONS TO SITE ADDRESS 0,2t)i-s I WI r if �,,,'}.�_ el T-I y e Y fit r 1/r,.c/
• 9f tY ) /Vr.r'-h lj'Rif, i) (" 5g i of, /
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YESO NO❑
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply)
SALTWATER g LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM 0
TYPE OF WORK: NEW 71, ADDITION❑ ALTERATION 0 REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence.Garage,Commercial Bldg,Etc.) 6 C/.V' l e
IS USE: PRIMARY,k SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS -
HEATED STRUCTURE? YES(Whole Bldg)❑ Y-�.
1 YES(Parris/of Bldg)❑ NO
DESCRIBE WORK (tC./L+C � -L-( : ►') ✓' 1,• ri1,1 S-.'
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 sq.ft. OTHER sq.ft.
GARAGE 710 sq.ft. Attached❑ Detached❑ CARPORT 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 Ft. SEWER❑ / NEW❑ EXISTING'i
PLUMBING IN STRUCTURE? YES❑ NOR. If yes.attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ rox 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 dedare 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
�Q 1 , COUNTY CODE 14.08.42) z,
p74 . Go zoz�J
Signature of OWN R(Mu t b siq d by the OWNER) ate
DEPARTMENTAL REVIEW AP OVED DATE DENIED DATE AGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH '5kt/43 (,&4T t1 (Lc
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