HomeMy WebLinkAboutBLD2023-00900 - BLD CD Environmental Health Review 3
DocuSign Envelope ID:4E477168-1A5B-4707-8846-4B9EC504495E �r�L pao Z
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATI N: dO s
NAME:DEBRA&DANIEL DEFFINBAUGH NAME:TO BE DETERMINED
MAILING ADDRESS:1510 E SPENCER LAKE RD MAILING ADDRESS:
Ci-T '::HELTON STATE:WA ZIP:9852.; -. ..ULTY. ---STATE:,.:. • -ZI'. --_4: — - .-_
PHONE#1:360-250-9258 PHONE: CELL: 0
PHONE#2: EMAIL : RF ,?Ql3
EMAIL:sistersfostering@gmail.com L&I REG# EXP._ /VFD
PRIMARY CONTACT: OWNER 0 CONTRACTOR❑ OTHER 0
NAME CHRIS ARNOLD-NW PERMIT SOLUTIONS,LLC-FOR PERMIT ONLY EMAIL CHRIS@NWPERMITSOLUTIONS.COM (����
MAILING ADDRESS 4631 WHITMAN LANE SE STE D I-\E CEI VEE D S Vj RO NrM E NTAL
PHONE 360-359-2967 CELL �/
HEALTH
PARCEL INFORMATION: MAY 2 3 2023
PARCEL NUMBER(12 Digit Number) 221314400060 ZONING RR10
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LEGAL DESCRIPTION(Abbreviated) �30FBLAII15,13AF02113107PTJE1M51/tSELY1NGWLV ER�d1�'S e'e FIRE DISTRICT NA
SITE ADDRESS 1510 E SPENCER LAKE RD CITY SHELTON
DIRECTIONS TO SITE ADDRESS HEAD E ON W ALDER ST TO N 6TH ST.AT CIRCLE TAKE N 1ST ST.TURN LEFT ONTO E PINE ST.CONTINUE
ONTO WA-3 N.TURN RIGHT ONTO E AGATE RD.TURN LEFT ONTO E SPENCER LAKE RD.DESTINATION WILL BE ON THE RIGHT.
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN l4%: YES❑ NO 0 SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND ❑ WETLAND 0 SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW 0 ADDITION 0 ALTERATION 0 REPAIR ❑ 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[s]of Bldg) ❑ NO 0
DESCRIBE WORK
SQUARE FOOTAGE: (proposed)
1ST FLOORS sq. ft. 2ND FLOOR 0 sq. ft. 3RD FLOOR 0 sq. ft. BASEMENT 2483 sq. ft.
DECK`%" sq.q.ft. COVERED DECK 0 sq.ft. STORAGE 0 sq.ft. OTHER° sq. ft.
GARAGE 0 sq.ft. Attached❑ Detached❑ CARPORT 0 sq. ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* In
MAKE NA MODEL NA YEAR NA LENGTH 67
WIDTH 40 BEDROOMS 4 BATHS 3 SERIAL NUMBER NA N
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC 0 SEWER 0 / NEW ❑ EXISTING 0
PLUMBING IN STRUCTURE? YES 0 NO❑ If yes, attach completed Water Adequacy Form ,
PERIMETER/FOUNDATION DRAINS PROPOSED? YES 0 NOD EXISTING SQ.FT. 5078
EXISTING BEDROOMS 4 PROPOSED BEDROOMS 2 TOTAL BEDROOMS 6
111J
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 APPR ►T��,N OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON
COUNTY CODE 14.08.42)
att' Rfutl05/23/2023
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68315D0133744C.
Signature of OWNER(Must be signed by the OWNER) Date
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i W j L. , D z ' z DEFFINABUSH REMODEL
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o 0 DEFFIA ?, I 1510 E SPENCER LAKE SHELTON. A9B584RD WP
z W N N REMODEL PARCEL NO.:22131-44-00060