HomeMy WebLinkAboutBLD2023-00848 - BRN Application - 7/26/2023 ;y
• MASON COUNTY COMMUNITY SERVICES Permit No: f.)I(I ,SU s 7) -W D
�, PERMIT ASSISTANCE CENTER: RECEIVED
y� BUILDING-PLANNING-PUBLIC HEALTH•FIRE MARSHAL
x •
I '�1� 615 W.Alder Street,Shelton,WA 98584
t -- '"::r.?a-..• i Phor-Shelton:(360)427-P57e ert.352•Fax:(360)427-7798 Phone
Sel(aic(360)275-4467•Phone Etna:(360)482-5269 J U L 2 4 7 23 2 __
BUILDING PERMIT APPLICATION 615 W. AIdP St
PROPERTY OWNER I FOR14IATION. CONTRACTOR INFORMATION: ` iiECEIVEpZ.
NAME: a}V1,t{ ( 1/c S �Vri NAME: c•
MAILING ADDRESS(1 E, _�_ ij'pvt LUNG ADDRESS: 2 J
CITY:�j►r�I-I--ot STATEW AZ :ogg5gc{ —CITY: STATE: ZIP:
PHONE#1... -`gar l 5(gq PHONE: CELL: Z <
PHONE#2: , 253-3$O -2 -1(p'g EMAIL: Q W
EMAIL: (-t a c e 5(p LCT ccL5f.ne-- L&T REG# EXP._/ / IC =
PRIMARY CONTACT: OWNER CONTRACTOR 0 . OTHER❑ 5
NAME I c^'{-ir.0 W t 111'[x.,Wl EMAIL i-r Ct.SLp (,CTWt-C&:.S1-.ne- z
MAILING ADDRESS (E g r CLT`o\ne. 14 D t•) AT ZIP CYgeS Si"(--/ w
PHONE ,Z3 -$fin-I5['I CELL SGZ Y_ bf .253- 5fp -A.cibs
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 12 C.)3(57 5l)O 12 D ZONING Z wr.e,/, R R Cz"C.rr--5
LEGAL DESCRIPTION(Abbrcviatcd)t'G}"I2 oi-SurVCAS UD12p 14 1 FIRE DISTRICT 5
SITE ADDRESS 'T t I E 1 ra.' ' w1 CITY
DIRECTIONS TO SITE ADDRESS OvNet P. 1 U c5h't tnC( tit C:ao.&w 6 4-Al 7Siu.Mck Dr.
r�i i-pv� .�A-% Is)ex 1\4 6)r J ri ct(n.-avt w o,rs-{vs-Pd }D to o n T►'I3191 rall"m U• *c 5 i,I-C:
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES NO 0 SNOW LOAD: psi
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check nil that apply):
SALTWATER 0 LAKE 0 RIVER/CREEK 0 POND 0 WETLAND 0 SEASONAL RUNOFF❑ STREAM 0
TYPE OF WORK: NEW 0/ADDITION❑ ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence Garage.D.mmvr.iu/Btdg,Ea) Pc;im CLA I?.c 5 t N isP. ee
IS USE: PRLMARY❑/cEASONAL❑ NUMBER OF BEDROOM 3 NUMBER OF BATHROOMS 'I
HEATED STRUCTURE? YES(Whole hldg)Er paws)of Mg)❑ NO❑
DESCRIBE WORK lye,'A..) YYLC C 5- r'tc.ki D✓t
SQUARE FOOTAGE:(prnpreerl)
1ST FLOOR 1%7). sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft BASEMENT sq.ft.
DECK sq.ft. COVERED DECK. 4 sq.ft. STORAGE sq.ft. OTHER sq.it
GARAGE 57(,, sq.ft. Attached[Detached❑ CARPORT sq.li Attached 0 Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
M MODE YEAR LENGTH
DTH BEDROOMS BATHS
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC Er SEWER❑ / NEW.2""*. EXISTING 0
PLUMBING IN STRUCTURE? YES' NO 0 L, IJ ves,attach completed Water Adequacy Form
PERIMETER/FOUNDATION//DRAINS PROPOSED? YES NOD EXISTING SQ.FT.
EXISTING BEDROOMS lJ PROPOSED BEDROOMS 3 TOTAL BEDROOMS
OWNER acknowledges that submission of inaccurate information may resuk 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 8 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
COUNTY CODE 14.08.42)
X� (ct. 7/I? 3
Signature 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 a 7/0elt &idfOri er[h/ M,
9- TOPCON
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