HomeMy WebLinkAboutCOM2019-00114 - COM Application - 2/27/2020 MASON COUNTY COMMUNITY SERVICES Permit NoLoyn 20j9- X I H
PERMIT ASSISTANCE CENTER: RECEIVED
" •BUILDING •PLANNING •PUBLIC HEALTH•FIRE MARSHAL
y� 615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone NOV 2 5 2019
Belfair:(360)275-4467•Phone Elma:(360)482-5269
•
BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: P heA- I r4 t r 'l NAME:
MAILING ADDRESS: So ;,, �.�� .�- ",A. F— MAILING ADDRESS:
CITY: 66,1 f n STATE: t t)f} ZIP: 9� CITY: STATE:- ZIP:
PHONE#1: 40o (C 4&`I b PHONE: CELL:
PHONE#2: EMAIL :
EMAIL: 1 o, L&I PEG# EXP.
PRIMARY CONTACT: OWNER CONTRACTOR❑ OTHER❑
NAME 1 �r ( EMAIL
MAILING ADDRESS ITY �Adf V STATE t-vk ZIP 7f554'
PHONE �--t`I � evg0 CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) �QQa— A Q� Cam-ZONING// (J �
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS '<-:J uJ (.J•o,j�L-v]a a CITY -,Iie j�:0
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❑ OTHER ❑
USE OF STRUCTURE (Residence,Garage,Commercial Bldg,Etc.)
IS USE: PRIMARY ❑ SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES (Whole Bldg) ❑ YES (Part[s]of Bldg) ❑ NO ❑
DESCRIBE WORK Q G�:
SQUARE FOOTAGE: (proposed)
1 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 REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ❑ SEWER ❑ / NEW ❑ EXISTING ❑
PLUMBING IN STRUCTURE? YES ❑ NO ❑ Ifyes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION 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.1 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.1 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 � I-25-Zo��►
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
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