HomeMy WebLinkAboutCOM2018-00036 FENCE - COM Application - 3/21/2018 MASON COUNTY COMMUNITY SERVICES _ 7
PERMIT ASSISTANCE CENTER: Permit No:� -M-k o
.BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL R
615 W.Alder Street,Shelton,WA 98584 E[ EI V
l Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone vvv D
Belfair. (360)275-4467•Phone Elma:(360)482-5269 1'AD (�
1854 MAR ? 1 2018
BUILDING PERMIT APPLICATION e'S V
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: Feet
NAME: �t S 1tiu� v. cDCsZ { (�t-w� NAME:
MAILING ADDRESS: aSa-S Ptkk-S k-4-- MAILING ADDRESS:
CITY: n r o m Vv f,)STATE: ZIP: 9 CITY: STATE: ZIP:
p �
PHONE#1: %p C q(o 140 PRONE: CELL:
PHONE#2: EMAIL :
EMAIL: O "tu L L&I REG# EXP.
4
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑
NAME EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) - 1{at36 — 314 10070 ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS SO L.4 (AA CITY $&f'un
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 0 REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) f+ J�e^et ( Via!
IS USE: PRIMARY❑ SEASONAL NUMBER OF BEDROOMS NUMBER OF BATHROOK4S
HEATED STRUCTURE? YES (Whole Bldg) ❑ YES(Part[s]of Bldg ❑ NQL
DESCRIBE WORK ence_ E>0 Imool+
SQUARE FOOTAGE: (propose+existing)
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.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: 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 permitlapplication 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)
Lx n� u __ g
Signature of OWNER(Must be sigrfed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
DocuSign Envelope ID:043D280E-D5C4-4725-8319-4FDBECA34014
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