HomeMy WebLinkAboutBLD2023-01325 - BLD CD Environmental Health Review - 11/6/2023 PROPERTY OWNER INFORMATION: CONTRACT
11OR INFORMATION:
NAME: ���pr 8�1,4�10E'MOR� NAME: MOM WtmL\UM )
MAIL GgQ ADDRESS: 14fiD >-e yyl�lAkR, y \ MAILING ADDRESS: E
CITY. ' QJN STATE:�(�ZIP: CITY:Q �gIV STATE: ZIP:LIA
PHONE#1:31nf� 4110—'J°1 lF) PHONE: CELL-
PHONE
PHONE#2: EMAIL : 1Y itlil a k lob
EMAIL: L&I REG#Yyr(u)\L1a(',L.
PRIMARY CONTACT: OWNER❑ CONTRACTOR t] OTHER&
NAME M EMAIL YYW� CAD
MAILING ADDRESS CITY P3MP=XM SfATE )LIA
PHONE tJ9.0 - Q101— 4bt�/lT CELL
PARCEL INFORMATION: k3
PARCEL NUMBER(12 Diet Number) ZA A 0552-DW Af, ZONING i
LEGAL DESCRIPTION(Abbreviated)}lr l C- *& 15 'j2-90 FIRE DISTRICT NQ.
SITE ADDRESSZPY50 Ca M0,8W i,,OKe C)X W cTTY�,lY6�N1�2HJ
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO SNOW LOAD:-_ psf
IS PROPERTY WITHIN 20A0 FT OF THE FOLLOWING: (Chectalldwit,*):
SALTWATER❑ LAKE C0 RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION❑ REPAIR❑ OTHER b0 Yt` 'CAY1C1')
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USE OF STRUCTURE(RcrNwroe,cage,caaweecudaWp,F,ta) 1
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS_
HEATED STRUCTURE? YES(whole Ndis❑ YES(Pare[a)ol1Ud81❑ NO d-
DESCRIBE WORK \O.0 1`Sh �
SOUARE FOOTAGE: (yrryuwd)
1ST FLOOR sq.O. 2ND FLOOR sq.R 3RD FLOOR sq.ft. BASEMENT sq.R.
DEC _sq.R COVERED DECK sq.R STORAGE sq.R. OTHER sq.R
GARAGE sq.fl. Attached❑ Detached❑ CARPORT sq.R Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED•
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTICt SEWER❑ / NEW EXISTING�..
PLUMBING IN STRUCTURE? YES❑ NOt j§- Ijyins,attach completed WaterAdequacy Form �-I
PERIMETERNOUNDATION DRAINS PROPOSED? YES❑ O� EXISTING SQ.Fr. 9 I k
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS •r
OWNER acvnowledges that submission of inaccurate information may result in a stop work order or permit revocation.Ad. mentor"of such is by
signature below.I declare that I am the owner and 1 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 holler 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 stmctum(s)for review and inspection. This permiyepplicalion becomes null 8 void ff work or authorized construction is not commenced within 180
clays 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
X /J�� q, t_ COUNTY CODE 14.08.42)
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Signature of OWNER(Must be signed by the OWNER) Date
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EH Setbacks
A.) DrainnelaReserve aeguifee 10 semackhorn fomingnuondanons
! 9.f 5eg d fanlr(s)r,U...5'sefbook from all f-angnoun canons
C)No bundaLon/Perimeter Drains wiMin 30X,downgradient of
} DralnOelNReserve area
( D.)No Gun Rank(s)(greater Ivan 511 and over 45 degrees)within
501 down gradient of Drai doll/Reeerve area
EH APPROVED
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