HomeMy WebLinkAboutCOM2023-00053 - COM CD Environmental Health Review - 6/6/2023 Tyco,': •T'4a:1,,, 1
MASON COUNTY COMMUNITY SERVICES Permit No: 4 )Z "}1 21 ) OOO'
' PERMIT •PL4NANCECCLiCHEA ECE(VED
T �! � .BUtLDlNG•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
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F- '0 615 W.Alder Street,Shelton,WA 98584
7_r-: ,..•'�'� �;• Phone Shelton:(360)427-9670 ext.352-Fax:(360)427-7798 Phone
� �y' Beltotr.(360)275 4467•Phone Data:(360)482-5269 • MAY I V 31 2023
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BUILDING PERMIT APPLICATION CONTRACTOR PROPERTY OWNER INFORMATION: VION' . Alder Street m
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NAME:MA Son [Q,t 'NO NAME: =
MAILING D RESS:Ll S I Ji t A)r i��$S g N MAILING ADDRESS: STATE: ZIP: J M
CITY:S � M 0
PHONE#1: (3C0) 8`i 1-S Z IN PHONE: CELL: D Z
PHONE#2: EMAIL: •
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EMAIL: JA"A r@ mas•n-ed✓1.or1 L&T REG# EXP. / /
PRIMARY CONTACT: OWNER VA CONTRACTOR❑ OTHR 0 • rn
NAMEZc wvt-a Qc r r. &S EMAIL 5 s r 0...en - NJ I , ur •
MAILING ADDRESS .Z(g11 q/ \1LPi 101 CITYShc1Fu,� STATE W( ZI�igSgy
PHONE (360111-SLN4 X Z IS CELL CS09)-'1l5-qo-L 6 ✓.
(--. PARCEL INFORMATION: .p O \ •
PARCELNUMBER(12 Digit Number) '32 Z LI 0 S 3 01 l';\ ZONING tZ 5 �C",
LEGAL DESCRITTION(Abbrcviated)A13 6)1-.,trs \Z K1 1Q-tA- It FIRE DISTRICT 5 <G ,-
CITY S 1,u.lk a v. �'
SITE ADDRESS N//� O
DIRECTIONS TO SITE ADDRESS Al- (o r n e( o c- AS., f3tKt� or n n,) 4 A3 n Iz 13[,,`I"
9\Eq.. ) S*w..J ero(r<rl- o,, rta1- site,. )0,71(..) l.or-}\- Ak E /13nkc (icq&t_ Or.
—1 IS THE PROTECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO tgl SNOW LOAD:16 psf •
ly):
SALTWATER❑ LAKE 2❑0 0 RIVERJCCRREEKL❑LO POND[1C WETLAND 0 SEASONAL RUNOFF❑ STREAM❑
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TYPE OF WORK: NEW❑ ADDITION giALTERATION❑ REPAIR❑ OTHER ❑- s USE OF STRUCTURE(Residence,Garage,Conner Bldg,Etc) S\0 r-&oiL
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Perr[s)ofBldg)❑ NO gi
DESCRIBE WORK Goo51^/ Qd(ti9 vit(Y,3
• SQUARE FOOTAGE:(prepoo Ii
1ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft
DECK sq.ft. COVERED DECK sq.ft. STORAGE '2.9 I sq.ft. OTHER sq.ft.
GARAGE sq.R 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❑ SEWER❑ / NEW❑ ELT^
PLUMBING IN STRUCTURE? YES❑ NO❑ 1./. a r completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? ❑ NOD EXISTING SQ.FT.
EXISTING BEDROOMS POSED BEDROOMS TOTAL BEDROOMS
OWNER acknowledges that s n of Inaccurate information may result In a stop work order or permit revocation.Acknowledgement of such Is by
signature below.I deco at I am the owner and I further declare that I am retitled to receive this permit and to do the work as proposed.I have .
obtained permission from ci 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 arcry to the above described property
and structure(s)for review and Inspection,This permitlappiicatlon becomes null&void If work or authorized construction is not commenced within 180
days or if construction worlds suspended fore 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 M oUNTY L
RE WILL CAUSE qHE APPLICATION TO BE EXPIRED.(MASON
C
CI- Zi- 202-3
2)
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Signature of NER(Must be signed by the OWNER) -
aTMENTAL RLVANy•T,r.APPI PaYil:i DA':0:"..::'_D,Y ED y DATL s`I'A DateGI, OTES/COND?TIOZ(S
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL � C.v�?lkIN C �L( ^ /)
PUBLIC HEALTH iZ�c�]f � ) S
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