HomeMy WebLinkAboutBLD2023-00300 - BLD CD Environmental Health Review - 3/17/2023 Hon o n MASON COUNTY COMMUNITY SERVICES �� „� �] I
+ r,, PERMIT ASSISTANCE CENTER: Permit`. .,. ._ _
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL '7
,cimt 615 W.Alder Street,Shelton,WA 98584 �48 �,
''•' Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Pho ?� M' C
Belfair.(360)275-4467•Phone Elma:(360)482-5269 of? ,,
23 J 2023
,�s.t �15 . A ckettreet rn
BUILDING PERMIT APPLICATION „�,1NN
,
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
/ _ 7
NAME: iii,' 71Ol /2(of*E / NAME: U/C 7)/ ,?Gt p L rn ®
MAILING ADDRESS: /- nN i MAILING ADDRESS:,Z-0 E( 1s-lori"CU/,,( A.-. -
CITY: A-�7`0/? STATE:tr/ft ZIP: 7,6 Y CITY: <-//7/4.:'77 STATE: cz,'! ZIP: 'S
PHONE#1: ,Z 5 5 7,S'5 /D70 PHONE: .,,c 9, /D D•`CELL: =rT1
PHONE#2: ,' > y'o /0 90 EMAIL : (//7:s-Mt-y'/,fir �iL.&G/7a,t/,cy/1'7
EMAIL: c//C-5/1,7c�l4*r/7/G. CG.Mc,/(On L&I REG# / EXP. / / .
Jor-
PRIMARY CONTACT: / OWNER 1] CONTRACTOR❑ OTHER❑ r
NAME (/l?C f /)5/T 44 EMAIL /
MAILING ADDRESS .zUV ,E zisk/.?-cL/fd/f I CITY j/f%'/749/? STATE /1/,9 ZIP `lY AY
PHONE , S-' PcS "/O/'O CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 3.;100 7//9603_3 ZONING 2
LEGAL DESCRIPTION(Abbreviated) FIRE DISITRIC
SITE ADDRESS
I T
I . CITY S 1�
CTI N TO SIT ADDRESS �. [ )2 " �� . -�`p G
cam o-c:v S 'Z. "' �-3 1 pll f Gnu tic-✓
IS THE PROJECT WITHI 300 FT OF SLOPE(S)GREATER THAN 1 /o: YES❑ NO
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
TYPE OF WORK: NEW ADDITION❑ ALTERATION ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) �xi,1' f
IS USE: PRIMARY SEASONAL❑ NUMBER OF BE ROOMS �� NUMBER OF BATHROOMS CTh
HEATED STRUCTURE? YES(Whole Bldg) ❑ YES(Part[s]of Bldg)t❑ N7
DESCRIBE WORK 0 4141C;hilt_ PO LL. 3-0614
SQUARE FOOTAGE: (propose+existing) J
1ST FLOOld . 'rsq.ft. 2ND FLOOR sq. ft. 3RD FLOOR sq. ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq. ft. OTHER sq.ft.
GARAGE 1'jO ),sq.ft. Attached❑ Detached laCARPORT sq. ft. Attached❑ Detached❑
r
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.K SEWER❑ / NEW❑ EXISTIN,
PLUMBING IN STRUCTURE? YES ❑ NEls If yes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES ❑ NOE< 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.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 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON
r COUNTY CODE 14.08.42)
X `' i,4!2 --�
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 040
�J,�PUBLIC HEALTH 0 `('a pe t
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