HomeMy WebLinkAboutCOM2020-00086 - COM Application - 10/20/2020 MASON COUNTY COMMUNTTY SERVICES Permit No:
PERMIT ASSISTANCE CENTER:
BUILDING.PLANNING•PUBLIC HEALTH FIRE MARSHAL
615 W.Aldar Street,Shelton,WA 96584
Phone Shelton:(360)427-670 ext.352•Fax:(360)427-7798 Phone C
BeffaN:(360)275 4467•Phone Erna:(360)482-6269
BUILDING PERMIT APPLICA ION
PROPERTY OWNER TORMATION• CONTRrA�CTO INFORMATION: 1 v 2020
NAME:a /NAME: a d t I �CY S
MAII.ING A RE SS 0: MAILING ADDRESS:
CITY: I STATE: �Z1P:�l CITY: 51 y STATE: ! ZIP:
PHONE#1: PHONE: 2 l CELL:
PHONE#2: EMAIL: xlt dt^cxa .c>,..
EMAIL. ,e t"W L I.&I REG# e _ EXP.�1�l?1
PRIMARY CONTACT: OWNER❑ CONTRACTOR, OTHER
NAME ffOI% ct Cldx4 f �) C T-tetu S EMAIL vr'••
MAILINGADDRESS I CITY STATE 0-10-�ZIp �
PHONE 175,7 CELL
PARCEL INFORMATION-
PARCEL NUMBER(12 Digit Number) "i�P} ZONING x
LEGAL DESCRIPTION(Abbreviated)5 (trma L / tnI FIRE DISTRICT k
SITE ADDRESS !O CLTX 5 a t
DIRECTIONS TO SITE ADDRESS f3e trc e�
IS THE PROJECT WTTHTN 300 FT OF SLOPES)GREATER THAN 14%: NO K
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that r 44;
SALTWATER❑ LAKE❑ RIVERICREEK❑ POND❑ WETLAND❑ S ONAL RUNOFF❑ STREAM❑
TYPE"OF WORK: NEW❑ ADDITION❑ ALTERATION REP ❑ OTHER ❑
USE OF STRUCTURE,_,(/Rasid..Garag4 coreraerrlal Bldg Ere)
IS USE: PRIMARY pLI SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS_
HEATED STRUGTUR�E�AA YY�ES(dfbale BW 64 YES Part!)oj�Jr(gd❑ NO❑
DESCRIBE WORK a tNi� cl sC ^-vf
SO.UARE FOOTAGE:(prop d)
LST FLOOR sq.fL 2ND FLOOR sq.& 3RD FLOOR sq.ft. BASEMENT sq.it
DECK sq.ft. COVERED DECK sq.& STORAGE sq.& OTHER sq.It.
GARAGE sq.ft.Attached❑ Detached❑ CARPORT sq.& Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES 01F THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAA4,NUMBER
ENVIRONMENTAL HEALTH-
SEWAGE/SEWER SOURCE: SEPTIC ' SEWER❑ / NEW AXISTINaWf
PLUMBING IN STRUCTURE? YES❑ NO If yes,attach completed Woter Adequacy Form
PERIMETERNOUNDATION DRAINS PROPOSED? YES❑ EXISTING SQ.FT.
EXISTING BEDROOMS_�� PROPOSED BEDROOMS TOTAL BEDROOMS e
OWNER admowledges that submission of fnaccurate Information may result In a stop work order or mnit revocation.Adurowiedgemerit.of such Is by
signature below.I declare that I am the owner and I further declare that]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 structures)for review and inspection. This pennitlappliration becomes null&void if work or authorUmd 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 CODE14.08.42)
re of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIEDOATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT j,
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH