HomeMy WebLinkAboutBLD2023-00640 - BLD CD Environmental Health Review - 6/6/2023 41.01111111
4.9�—°° � MASON COUNTY COMMUNITY SERVICES N C_0a0a 'CO(c95
..ri,
`IF. PERMIT ASSISTANCE CENTER: _L.
, .BUILDING-PLANNING.PUBLIC HEALTH.FIRE M4RSI4L ENV(°F- il r s
1rs � ~ 615 W.Alder Street,Shelton,WA 98584 '/I y ty4ENTgis
\' f Phone Shelton:(360)427-9670 exL 352•Fax:(360)427-T798 Phase J U N — 6 2023 H E
?2r\ �cv
f Belfair.(360)2754467.Phone Elms:(360)482-5269 A LTH
BUILDING PERMIT APPLICATIONIder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: . LMt.S 6:7ACk ,l NAME:COV0.\ HOMC$ 1l-C-
MAILING ADDRESS: 840 V-gt*S t t Rd. E MAILING ADDRESS: 1-02.3 l 23•�' %-4- e.
CITY: CAZI40.t STATE:W* ZIP: 19 3616 CITY:T0.00 MQ STATE: W P ZIP: q 81-t45
PHONE#1: 1'10• (0 2\•I t81 PHONE:2.53•1:1593•WILL:
PHONE#2: EMAIL:bCQk,COvak ONkeS •COON
EMAIL:,.0.Ml.S o)kck k ta UO LO •COM L&I REG#COVRLEIL8,14 COLD EXP. t't/LI/-2-.3
PRIMARY CONTACT: OWNER❑ CONTRACTOR 0 012IER
NAME T . SON%Nate EMAIL kk10.Q 0.S•l t'C W..tt
M .COS
MAILING ADDRESS 130 aQX tSG 3 CITY Q�}a cbos STATE V4A ZII��S
PHONE 3G )•`I30.2 F I CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 51°108- -00033 ZONING if\h0kcii(15AdapSkS
LEGAL DESCRIPTION(Abbreviated) SA G-e {,AY-Q.4/rI \.ak-: 33 S 5li c)FIRE DISTRICT 13��
SITE ADDRESS 421 W setzl 'lc be CITY F-lM0.
DIRECTIONS TO SITE ADDRESS 'R.L &1.1tRAt #0 eAttter S4'dc\o3eg. CAM'Etf• w{- iCt cn4C'aCNI'i.•fit\
le44 CAA0 Sa•\SoP Dr. C c*tmu a cc‘ c .-ccj P Or UJ*tl *ANL Cool C-CONtC,'lab ckcktcudt encL.
i IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES rA.... NO❑ SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF i'HI±.FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE 0 RIVER/CREEK❑ POND 0 WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW IA ADDITION❑ ALTERATION❑ REPAIR 0 OTHER
USE OF STRUCTURE(Residence,Garage,Commercial Bldg.Etc.)
IS USE: PRIMARY 0 SEASONAL 0 NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)0 YES(Part(sJofBldg)❑ NO❑
DESCRIBE WORK R2k-Clifl:(\ shall k
SQUARE FOOTAGE:(proposed)
1ST FLOOR sq.ft 2ND FLOOR sq.ft 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.IL STORAGE sq.ft OTHER sq.ft.
GARAGE sq.ft.Attached❑ Detached❑ CARPORT sq.ft.Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF I'Iili.FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC D3• SEWER❑ / NEW®, EXISTING❑
PLUMBING INS I RUCTURE? YES❑ NO❑ Jfyes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOD 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 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.1 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 properly
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
COUNTY CODE 14.08.42)
x
'a,n�� JoI 5tWt 02 /01 /2023
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTALREVIE* APPROVED' DATE [DENIED__ DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH OI k- �//
W/013 Conai f icri ad-deg 1
Doc ID:7940dd8bbeOfb�8e2f4863d30143cb23a0745066 1
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