HomeMy WebLinkAboutBLD2023-00576 - BLD CD Environmental Health Review - 6/4/2023 1��' MASON COUNTY COMMUNITY SERVICES Permit No:1/IG 1 42O2' ' VV i / Le
V/`r,,„t , PERMIT ASSISTANCE CENTER:
'ca t,.•BOWING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
5
615 W.Alder Street,Shelton,WA 98584
': •- .�; Phone Shelton:(360)427-9670 ext.352•Fax(360)477-7798 Phone
.fir'' r,,t�t`t \ Batten-(360)275-4467.Phone Elmer(350)482-5269
qBUILDING PERMIT APPLICATION m
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PROPERTY OWNER INFORMATION: CONTRA OR INFORMATION: Z
NAME: ire(r QI�!r J� C(� E NAME: t! OW ne
MAIL ' S: I MAILING ADDRESS: :...
CITY: : .3D( CITY: STATE: ZIP: r'
PHONE#1: /t PHONE: CELL: Z
Mi PHONE ifiC-
Y W� Choate) EMAIL:
EMAIL: AQ f jar U'e/LJ ilia iI•GdAv , i L&I REG# EXP._/ /_ L:1 rn
PRIMAR CONTA OWNER I CONTRACTOR❑ OTHER❑ 2 Z
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NAME i w' EMAIL --1
2 MAILING ADDRESS CITY STATE ZIP D
PHONE CELL
9 I PARCEL INFORMATION:
C��C7�l`
PARCEL NUMBER(12 Digit Number) ZZ l — -9 Zt /f ZONING ,f i
LEGAL DES O' Abbres" led) FIRE IS CT
SITE ADDRESS • CIT.Y ��
D] Urr''IONS TO SITE AD FSS • �1I 144 Pt I/
IS THE PROJECT VI'I"I I 1300 FT OF SLOPE(S)GREATER THAN 14°/.: YES❑ NOOS:SOW LOAD:1ir psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: ICherk ell dm;apply):
SALTWATER❑ LAKE❑ RIVE ' K❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW ADDITION fl ALTERATION❑ REPAIR❑ OTHER n
USE OF STRUCTURE/(Retare.Clo nge.Commerrial Bldg.Etc) 'ell del 7Ce
IS USE: PRIMARYASONAL❑ NUMBER OF BEDRO(VIS 2 NUMBER OF BATHROOMS //1� ��qt ►/(��
HEATED STRi ? YES Itrh,d aldgl❑ YES rPnntyofaldg)4" NO yie /A / /� 4o/ M /';` ( c
DESCRIBE WORKI�'. l� r 4(� t/yW,/1�IIL�PACC, O/� (2 r�1.4sA7�n1�G�t1
S UARE FOOTA rpopposed)
1ST FLO vsq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft_ BASEMENT sq.R.
DECK s.q.ft. COVERED DECK sq.ft. STORAGE sq.ft OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFA ON: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MA MODEL YEAR LEN
\ DTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES , NO❑ If yes,attach
�camp ed WaterAdega in acyFor
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOU' EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS Z TOTAL BEDROOMS
OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement at 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.inducing 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&vc id if work or authorized construction is not commenced within 180
days or if uuroruction 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
X
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
4 -46-:' /t7( /Z,Z
Si ature of OWN R ust be si red b the OWNER e
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL �n ���( .f /� /��
PUBLIC HEALTH 00 6(00` cr• r 0 S /�L 1-
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