HomeMy WebLinkAboutGRD2011-00003 - GRD Application - 4/19/2011 T
FORM MUST BE COMPLETED IN INK )60q iq 00000
PLEASE PRESS HARD PERMIT NO.: GRD t I
MASON COUNTY
LAND MODIFICATION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT NFORMATION /I CONTRACTOR INFORMATION
Owner -L mX s en� 6fv, I,LC- Contractor Name Mailing Address 6Y o lzs nr• G MailingA dress .0•il
Dx lb
M City ® Ilk State, Zip Code 29so City C g State Zip Code YPS32
Phone pro-6192- Other Ph.(_____) Ph.(36o ) '7N -�.Oq I Other Ph.( 3l�o
Lien/Title Holder Contractor Reg. # ZC,coMGC 44/ 30
Address �s .>rt� .x Expiration__/
ENGINEER INFORMATION _
Name `cAt i f- � , End W LI� h 3 ti i Phone (3GO ) 7S ` 31
Address 'l i1/L- v�rr( d (3CIF-, State Zip Code
PARCEL INFORMATION-12 digit Tax Parcel No. .-r / / Fire District
Legal Description
Site Address(includ street me and city
Dirertio s to site: !r d
'FT��d�
Will timber be cut and sold in parcel preparation? (Yes/No) -C
Is your property within 200' of the following: Body of Water(Name) 4/011 r__ Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs Soft compressible soils
TYPE OF JOB - Excavation _Filling X Grading _ Total size of area 110 eec,-es 4 �o
Size of area to be clear d on slopes over 10% S Estimated amou t of c bic yard6 NO ouo -F
Describe Work roc),r .sf r aces, en.<-r rarl e/'vSQx yn >c�a God lir.� s01
LAND MODIFICATION INFORMATION YES NO
Will fill be brought on site? If yes, source E3 X
Will excavated materials be taken off site? If yes, destination 13 Xf
Does fill contain potential hazardous materials? 13 9
Has a soils report been completed on site? If yes, include copy. A 0
Will proposal result in redirection of any surface water runoff onto adjacent properties? 0 Er
Will proposed work alter where storm water or ground water enters or exits the site? 0 Ell
Will quality, quantity or velocity of storm/ground water be altered? 0 El
Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? )a
Will the land be replanted upon completion? 11 0
Will the proposal result in slopes steeper than those currently on site? 0
Is the site within 200' of a designated shoreline? 13
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-]certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued
Ewill be done' conformance therewith. No changes shall be made without an II work.shall be done in conformance therewith. No changes shall
tainin -ppproJv�al. / be a i out first obtaining approval.
MJU� �1 M-fe+� Date �� �a�I X . rZ.C_ Cv^Q , .3: [ ate /�-�{
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED _ _ CONDITION CODES
Building Department
Planning Department
Public Works Department
Fire Marshal
FEES
Grading Permit Fee Site Inspection
Plan Review Fee Other
Public Works Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES