HomeMy WebLinkAboutCOM2020-00012 Unmanned Telecommunications Facility (Monopole) - COM Application - 5/13/2020 PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: C cC c
NAME:_Mason Count NAME: TO Bid C' �
MAILING ADDRESS: ILING ADDRESS:
CITY: Shelton STATE: ZIP:_98584 CI Y: STATE: ZIP:
PHONE#1: _ _ r P ONE: CELL:61•S �/. Alder c t
PHONE 92: E R, :
EMAIL: L I REG# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR[] OTHER U
NAME EMAIL irnhPrts tilsontech COm
MAILING ADDRESS CITY Portland STATE GR ZIP 97204
PHONE _ - L,
206 719 6452 CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 4.20021000010 ZONING 72-REC.-PUBLIC AS EM
LEGAL DESCRIPTION(Abbreviated).LOT 1 0 F S H 0 RT S U DIVISION 3123 FIRE DISTRICT
SITE ADDRESS W. Public Works D ive CITY Shelton
DIRECTIONS TO SITE ADDRESS US-1 01 N left on WA-102 W right on W. Public Works Dr. destination
will be on right
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER T IAN 14%: YESW NO ❑
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE ❑ RIVER/C EK ❑ POND ❑ TLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
TYPE OF WORK: NEW® ADDITION ❑ ALTERATION ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) Unmanned Telecommunications Facility (Monopole)
IS USE: PRIMARY[� SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg) ❑ YES (Part[•,]of Bldg) El NO
DESCRIBE WORK Construct 120' A L monopole w/ 6 a tennas and SUDporting equipment
SQUARE FOOTAGE: (proposed)
1ST FLOOR sq. ft. 2ND FLOG 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: x4 COPIES OF THE FLOOR PLAN REQUIREDx
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER ft
ENVIRONMENTAL HEALTH: 41%#%J I L.1)/Af
SEWAGE/SEWER SOURCE: SEPTIC ❑ SEWER❑ / NEW❑ EXISTING ❑
PLUMBING IN STRUCTURE? YES ❑ NO ❑ Ifyes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PR POSED? YES ❑ NO❑ EXISTING SQ.FT.
EXISTING BEDROOMS ROPOSED 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 entit ed to receive this permit and to do the work as proposed. I have
obtained permission from all the necessary parties,including any easement holdE r 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 pe mit/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 1 .08.42)
X
Signature of OWNER(Must be signed by the OWNER) Date
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