HomeMy WebLinkAboutBLD2018-01090 - BLD Application - 10/4/2018 I� BUILDING PERMIT APPLICATION 1 a01a-
PROPERTY R INFORMATION: CONTRACTOR INFO DE1VED
NAM NAME:
MAILING ADDRESS: MAILING ADDRESS: --e
CITY: STA ZIP:tZ CITY: o STATE- ZIP..*- �t
PHONE#I: � B 7 7/2- PHONE:^e c�C CE�• HI
PHONE#2: EMAIL :
EMAIL: T------ L&I REG# EXP. /
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑
NAME EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION: G
PARCEL NUMBER(12 Digit ber) 12 119-50- (n (o0 ZONING �y
LEGAL DESCRIPTION(Ab revi ed) FIRE DIST``RIC��T""""
SITE ADDRESS�� E of 70 CITY ShQ�t��yk:
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: 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 El OTHER [IUSE OF STRUCTURE(Residence,Garage,Co-mercial Bldg Etc.) Cam(WA41f f e
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF IiEDRO&S NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg) S(PartivofBldg)❑ NO❑
ax-
DESCRIBEWORK h10VI ("8'5,� 6 r-*'&- 44-U— CAA-
SOUARE FOOTAGE: (Prop—P.existing)
I ST 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❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN RED*
MA MODEL GTH
MA
EE BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO❑ If yes,attach completed Water Adequacy Form
PERIMETERNOUNDATION DRAINS PROPOSED? YES❑ NO❑ 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
� COUNTY CODE 14.08.42)
X
Signature of OWNE ust be s' ned by the OWNER Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT