HomeMy WebLinkAboutBLD2021-00365 Repair Tree Damage - BLD Application - 3/11/2021 MASON COUNTY COMMUNITY SERVICES Permit No: b d 262.1 - 6020lj
PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
Belfair:(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:5) D SSon E yia•tA ��1 NAME: Q h��S�Lt �S�` Cam'Y. on
MAILING ADDRESS: E MAILING ADDRESS: 23o t SE Art-"'c- >2,_
CITY51,¢.1 fty\ STATE: P, _ZIP:I'd CITY:S hA�t+Ly� STATE:_ZIP: 9 rS
PHONE#1: 2t,'Xo --I 2-4 73 25 PHONE: `f2-Co 1,42'7 CELL: ::7o7 599 54t�(o
PHONE#2: EMAIL : - C o
EMAIL: S Q-v o 3 r d @(A bI •Go r-1 L&I REG# o EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTORK OTHER❑
NAME EMAIL CL�I •Ga
MAILING ADDRESS 2301 g4Q: 8y-c"'a a-8 CITY S STA a ZIP
PHONE ` -L* U 4Z"� CELL 7 01 S9 9 !T40(.,
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) / 2I 9 —5 7- O 00 'y`� ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS 7 q 9 C P r p rn 0 n-{p►'z , 9.4 CITY S/,p,/fa n
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑ SNOW LOAD: psf
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 PQ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) Q Q_S%cffe✓1 C—C
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg) ❑ YES(Part[s]of Bldg) ❑ NO ❑
DESCRIBE WORK �Y1"5 cw I
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 ❑ 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 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 -� �2
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT ✓/C— S/Z Z(
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
MASON COUNTY Shelton (360)427-9670 ext. 352
. , DEPARTMENT OF COMMUNITY SERVICES Belfair(360)275-4467
Mason County Bldg. 8, 615 W. Alder Street Elma (360)482-5269
Shelton, WA 98584
www.co.mason.wa.us
REQUEST FOR BUILDING PERMIT EXPEDITION
Date:
Permit No.: l)Icy ZOZI- 3U5
Name: Pv� 5 A -en S
Mailing Address: 2'-50( SC-- Ar«.,d-,il&- U-d
S� ,n 9�s
Parcel Number: /�2-/I 9— ;-7 — 000 296
Site Address: -707 Frar4orl47��-L,—
Sole l 6-�:r5V
Request due to: ❑ Medical Hardship ❑Fire Damage [Other 1
Explanation of Hardship: f/'-Le Ae' // -J�✓ "yG i't Q e- iU
Must include supporting documents.This may be a letter from a doctor, insurance claim report, report of fire damage
from appropriate fire district representative or other relevant documentation.
I (WE) understand the intention of this form to determine and document justification for expedition of a building
permit to alter or r uct a structure on the above named property.
Signature Ow er/Agent:
OFFICIAL USE ONLY
Request: *Approved ❑ Denied Date:
Request denied for the following reasons:
Signature: (Ctk V
Director of Community Services