HomeMy WebLinkAboutCOM2018-00119 - COM Application - 11/19/2018 MASON COUNTY COMMUNITY SERVICES Permit No: C6M �t8 - 6D 119
p: PERMIT ASSISTANCE CENTER:
,,•BUILDING.PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98684 ,, L
Phone Shelton:(360)427-9670 ext 352•Fax:(360)427-7798 Phone
Selfair.-(360)275-4467•Phone Elma:(360J482-5269
OCT I G c018
BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNED.INFORMATION: CONTRACTOR INFORMATION:
NAME:State of Washington NAME: To Be Determined
MAILING ADDRESS:631 W --ortrt Rd MAILING ADDRESS:
CITY:Shelton S A ZIP:98584 CITY: STATE: ZIP:
PHONE#1: PHONE: CELL:
PHONE#2: EMAIL :
EMAIL: L&I REG# EXP. / f
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHERRI Engineer
NAME EMAIL
MAILING ADDRESS 111 Fawcett Aye. Ste 10Q CITY Tacoma_ STATE_ zip
PHONE 253-3 1�2`57 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 [5J
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER❑ LAKE❑ RIVEWCREEK[] POND❑ WETLAND ❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION❑ REPAIR 2 OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,H,) Commercial
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)N YES(Part jsl of Bldg)❑ NO❑
DESCRIBE WORK
S UARL+i FOOTAGE: (propose+existing)
I ST FLOOR q.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 El Ifyes, attach completed WaterAdeguacyFonn
PERIMETERIFOUNDATION DRAINS PROPOSED7 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,)declare that i am the owner and 1 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 permit(applicatlon 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.