HomeMy WebLinkAboutCOM2018-00118 - COM Application - 11/19/2018 �o cQv MASON COUNTY COMMUNITY SERVICES
PERMIT ASSISTANCE CENTER: Permit No;
";•,•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL i
615 W.Alder Street,Shelton,WA 98584
IF
ll' phone Shelton:(960)427-9670 ext 352•Fax:(360)427-7798 Phone OCT 10 2010
�- Belfair.(360)275 4467•Phone Elrrra:(360)4$2-526l3
- 1854
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: GI BUILDING PERMIT APPLICATION
615 W.Alder Street
PROPERTY OWNE INFORMATION: CONTRACTOR INFORMATION:
NAME:State of Washington NAME: To Be Determined
MAILING ADDRESS:631_W Dayton Airport Rd MAILING ADDRESS:
CITY:Shelton STATE:-pIA ZIP:98584 CITY: STATE: ZIP:
PHONE#I: PHONE: CELL:
PHONE#2: EMAIL :
EMAIL: L&I REG# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHERE Engineer
NAME EMAIL
MAILING ADDRESS 1 11 Fawcett Aver Ste-1 00 CITY Tacoma STATWZA-___- zip
PHONE 253-383-3257 CELL 253-227-8659
PARCEL INFORMATION:
PARCEL NUMBER(I2 Digit Number) 42002-32-60010 ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS 631 W Dayton Airport Rd CITY Shelton
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 2 OTHER ❑
USE OF STRUCTURE(Residence,Garage,ContmerclalBldg,HI) Commercial
IS USE: PRIMARY❑ SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUC YES More Bldg) YES(Part(J of Bldg)❑ -NO E
DESCRIBE RK I 1'lC��(I '17 • Wt�"`''�''� .
SQUARE O A {: (propose+existing) 'n
��t.
IST FLOOR sq.ft. 2ND FLOOR sq.ft. 3 q.• sq.ft.
DECK sq.tt. COVERED DECK sq.ft. STORAGE sq."fftt. OR sq.ft.
GARAGE sq.ft. Attached❑ Detached El 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,i declare that i am the owner and I further declare that 1 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)
X 7.25.18
Richard VER(Must be signed by the OWNER) pate
washington state Patrol
DEPARTMENTAL REVIEW APPROY DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT W I('
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH