HomeMy WebLinkAboutBLD2023-00610 - BLD CD Environmental Health Review - 7/26/2023 „°```":n c .-. MASON COUNTY COMMUNITY SERVICES
A •.` PERMIT ASSISTANCE CENTER: Permit No:dLPO p°Lc le
' • '1 •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHA E C E
X 7 VED
• 4,� 615 W.Alder Street,Shelton,WA 98584
”'�i A Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 •honeJU 9
-v T;SI Belfair:(360)275-4467•Phone Elma:(360)482-5269 l ` 6 2023 JUN — 1 2023
BUILDING PERMIT APP - • 6 Z4 ' 15 W. Alder Street
•
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
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NAME: go6E((-T C. 17vkk NAME: h.NVII�ONMENT
MAILING ADDRESS: 1b1 ( . 1.1Kom itae'' re_ MAILING ADDRESS: HEALTH
CITY: G pAAE /i ,s STATE: („SA. ZIP: g ' 4t CITY: STATE: ZIP:
PHONE#1: "1Ir1 •you-`100-7 PHONE: CELL:
PHONE#2: 11q-44 to - 9'114 ti EMAIL :
EMAIL: L&I REG# EXP._/ /_
PRIMARY CONTACT: OWNER" CONTRACTOR❑ OTHER❑ 1
NAME EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION: •
?C PARCEL NUMBER(12 Digit Number)_Z2121 -5-1- 0O o 4 y ZONING
LEGAL DESCRIPTION (Abbreviated) FIRE DISTRICT
SITE ADDRESS Ile 1 C. VkAae.LE 6E,tty DR CITY Ci_12.40Evi E.f J 1 f t•4 9 Qs-'6
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14a/0: YES El NO❑
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER ❑ LAKE ❑ R1VER/CREEK ❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM❑
TYPE OF WORK: NEWX ADDITION ❑ ALTERATION ❑ REPA ❑ OTHER ❑_
USE OF STRUCTURE (Residence,Garage,Commercial Bldg,Etc.) UD % Y'OOVA
1S USE: PRIMARY ❑ SEASONAL ❑ NUMBER OF BEDRO S NUMBER OF BATHROOMS , •
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Part[s]o(Bldg) ❑ NO ❑
DESCRIBE WORK 90-0 0
SQUARE FOOTAGE: (propose+existing)
1ST FLOOR sq.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 sq.ft. Attached❑ Detachedf CARPORT sq. ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
i MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ❑ SEWER / NEW El EXISTING SIC
PLUMBING IN STRUCTURE? YES" NO ❑ I f yes, attach completed Water Adequacy Form
PERIMETER/FOUNDATTON DRAINS PROPOSED? YES ❑ N 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
-ciljnatueitiberdo Iae7afe that I Writhe owner and tfurthe(declare that I am ei ONed to iecerve-8iis pamilt aid to do the work as proposed.I have
obtained permission from al 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 stnrebse(s)for review and Inspection.This pennl/appllcation becomes null&void If work or authorized construction is not commenced within 180
constructiondays or If 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
P UCATION OF 18 YS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X p‘ - DI— Z3
Signature ER(Must be signed by the OWNER) Date
PART1iir:a07,irrikr•;�-^i gROVEDT'; D A'I el't:t_D (IFi i,: ;;A1- .'.TAGS/ OTE$/4.QDITTONS _
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL ,/
PUBLIC HEALTH ' �/r/,2 /Y 0 AC, •