HomeMy WebLinkAboutBLD2023-00476 - BLD CD Environmental Health Review - 5/1/2023 yctt;'c.pj MASON COUNTY COMMUNITY SERVICES Permit No:SILO OLO 3 '�q7(0
e� PERMIT ASSISTANCE CENTER:
r ��1. ••BUILDING••PLANNING••PUBLIC HEALTH••FIRE MARSHAL
6 •1 1• •A 615 W.Alder Street,Shelton,WA 98584 RECEIVED
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�-f Phone Shelton:(360)427-9670 ext.352•Fax (360)427-7798 Phone
4 y. Bellair (360)275-4467•Phone Elmo:(360)482-5269
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BUILDING - 1 2L I N V iV'iM E N TAL
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION:- CONTRACTOI1 iNFURI� N$Irc.c�+ EALTH
NAME:�Y CMG11n`�cck tac\(t Jb NAME: (A)\10tA kt UM-5
MAILING ADDRESS:TO _ ,D1- 14-)a- MAILING ADDRESS: 1G(9O 9Ot>f-C.Y' PtdC
CITY: Shea (y'\ STATE:TWA ZIP: g t L} CITY:IAA't QV"(,hf:LYG1 STATE:W P ZIP:0,4 W 1p
PHONE#1: U�)-HWPC-10`ca) PHONE:3UD-1ptp2-151-WELL:
PHONE#2: 101)• `'��(.P3-to,,1-k EMAIL:UDVYSt,Mlfil tine Coy a1hu rat 5,GOirn
EMAIL:vvJUI{3 4`61 9mCw-Corn L&I REG# EXP. /_/_
PRIMARY CONTACT: OWNER® CONTRACTOR 0 OTHER 4]
NAME ?1Y0tf10I1 Ulf- EMAIL 1-WR.4 3 �1 k.�9(Yxi,f t. OW()
MAILING ADDRESS_F 0 ?s (u'7:- CITY J+'1G ltT 1'1 STATE WI ZIP hBcSy
PHONE CELL 3l00-41.0. '103v
PARCEL INFORMATION: �} ,^� .c y t y is
PARCEL NUMBER(12 Digit Number) 3L l 2l[�" G� C���+VZ" ZONING. u-'{0.k _I. C.'CICAN-h `
LEGAL DESCRIPTION(Abbreviated)jGt 2-of SQ #3151✓ PF i•zioct(033 t nv`f nub' t `p30' or. sec- 2-1
SITE ADDRESS SOi ti• WO M v4 y ti:Ylk '�-d CITY `)f 1L W0'(1
DIRECTIONS TO SITE ADDRESS off MC't&Qfl Late t2 4
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NOTII SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE 0 RIVER/CREEK❑ POND❑ WETLAND jfi SEASONAL RUNOFF[ STREAM 12t,
TYPE OF WORK: NEW tit ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
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USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) 1 e S t cken Lt,
IS USE: PRIMARY(1,. SEASONAL❑ NUMBER OF BEDROOMS le NUMBER OF BATHROOMS 2 3 14
HEATED STRUCTURE? YES(WholeBldg1 IQ YES/Part/s)ofBldg)❑ NO❑
DESCRIBE WORK NZV'4 StiLA( b'vkilt- tocrnc Vjtifle) b�ik'
SOUARE FOOTAGE: (proposed)
1ST FLOOR tq)(p sq.ft. 2ND FLOOR 12.t sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK 10t• sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE` 2.t( 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 Di SEWER❑ / NEW` EXISTING❑
PLUMBING IN STRUCTURE? YES(. NO 0 lives,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES' NOD EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS kt TOTAL BEDROOMS kp
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 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
J�6`� OUNTY CODE 14.08.42)
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Signature of OWNER(M t be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL ^_ Q ,_ C
PUBLIC HEALTH YReif— C g f r/ r3 "�^�`'" '`^" c
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