HomeMy WebLinkAboutCOM2023-00069 - COM CD Environmental Health Review - 7/20/2023 rsox cov,,r MASON COUNTY COMMUNITY SERVICES r�r,O��
4'i ' PERMIT ASSISTANCE CENTER: Permit No:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL' 615 W.Alder Street,Shelton,WA 98584 2023
�� Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone �(lll
Belfair:(360)275-4467•Phone Elma:(360)482-5269 Wf
\ tx.tl/ 615 W. Alder Str et JUL 2
BUILDING PERMIT APPLICATION 0 Z023
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: RECEIVED
NAME: .)-.'h-12 Pad 144/1 NAME:
MAILING A DRESS: C C 15cX Kj- tr MAILING ADDRESS: m
CITY: f 1<,'Ir. STATE: ivi4 : sibri& CITY: STATE: ZIP: Z
PHONE#1: "S C (t -2_('c 1%O l.' PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: I r y
y c 1aC1 (/Ar1 f1Gt(, tfeI- L&I REG# EXP. / /_ = DO
PRIMARY CONTACT: OWNER W. CONTRACTOR❑ OTHER❑ A 2
NAME EMAIL r " +�
MAILING ADDRESS CITY STATE ZIP ,CI S
PHONE CELL = m
PARCEL INFORMATION: z
Zdt PARCEL NUMBER(12 Digit Number) `S ) ('0 ZONING C C; D
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT I—
SITE ADDRESS (71(,0 ) ' Pal F.4. CITY )1,10 6s
DIRECTIONS TO SITE ADDRESS 11 t.t tc-4-r+1 IQ✓`C cArt 1444 ('`'t Vidtir
1
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NOV
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` ❑
/ 1
USE OF STRUCTURE(Residence Garage.Commercial Bldg.Etc.) Ci is'(.t..1 (0,1 S Kii `t
IS USE: PRIMARY❑ SEASONAL®, NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? S(Whole Bldg) YES(Part(:]ofeldg)❑ NO I
DESCRIBE WORK i G '( 6 CA:l d i c^1 r ltii[i C ei 5 -?c"
SQUARE FOOTAGE:(propose+existing)
1ST FLOOR 3(Q sq.ft. 2ND FLOOR sq.fL 3RD FLOOR sq.ft. BASEMENT sq.tt.
DECK sq.ft. COVERED DECK sq.ft STORAGE sq.ft. OTHER . sq.ft-
GARAGE sq.R Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF TILE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC$ SEWER❑ / NEW❑ EXISTING g
PLUMBING IN STRUCTURE? YES NO If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NOD EXISTING SQ.FT.
i 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 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 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
PERIrT,PPLICATIO 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
/ COUNTY CODE 14.08.42)
X7.6/7/2./ clog 24
ignature of OWNER(Must be signed by the OWNER) ate
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL / . '7 /r n i-
PUBLIC HEALTH et7/�- TA/4 tea►FL. V �'`� ( t Na/