HomeMy WebLinkAboutBLD2023-00743 - BLD CD Environmental Health Review - 6/29/2023 MASON COUNTY COMMUNITY SERVICE PtNo:PERMITASSISTANCE CENTER:
BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHALIVED
615 W.Alder Street,Shelton,WA 98584JU
Phone Shelton:(B60)42TS670 axt.352•Far:(36a)42-52 98 Ph 2023
Bellair.(380)2T5-046]•Phone Elma:(360)9825269 EBUILDING PERMIT APPLICATIOer Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: NAME: CT_K/IySTyi/t 56Y/ I6'lSr,jCf
MAILING ADDRESS: 7 MAILING ADDRESS: lO1 P 2, a e
CITY: ,SHff_Mt) STATE: (AA ZIP: j8ZV CITY: .S 41umw STATE: WX ZIP: sFssc./
PHONE#I, PHONE: CELL: 366-V90-V5/01
PHONE#2: EMAIL; Q'
EMAIL: L&I REG# EXP.
PRIMARY CONTACT: OWNER[I CONTRACTORS OTHER[]
NAME EMAIL
MAILINGADDRESS,i6_t F_ A2 -pt.1mn nr CITY Cmffr ul SATE A"A__ ZIP TfSFr6
PHONE CELL .346- S'roi "Peel
PARCEL INFORMATION:
PARCEL NUMBER Digit 12 i Number
( ® ) 319c-1 64 c000 I zoxwG
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITEADDRESS 17Ao SF rr-g SGtAT jr CITY 'tljeec4a'_)
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YESE NO❑ SNOW LOAD•1S osf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Ch katl aav,,pty):
SALTWATER❑ LAKE N RTVER/CREEK 0....POND.❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEWE ADDITION❑ ALTERATION❑ REPAR O OTHER n
USE OF STRUCTURE(rt wmae Garge,Commercial Borg,
IS USE: PRIMARY ff SEASONAL❑ NUMBER OF BEDROOMS_ NUMBER OF BATHROOMS_
HEATED STRUCTURE? YES(n kisldg) III YES(Pan(e)oy 150g)[INO
DESCRIBE WORK OEIA) S4�{e
SOUARE FOOTAGE, rprepg..m)
I ST FLOOR 11 GA sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.R BASEMENT -TIY sq.ft.
DECK_sq.R COVERED DECK sq.R. STORAGE sq.& OTHER sq.ft'
GARAGE_5rlg?__sq.ft. Attache Detached❑ CARPORT sq.ft. Attached❑ Detached
MANUFACTURED HOME INFORMATION: w4 COPIES OF THE FLOOR PLAN REQUHRED-
MAKE MODEL YEAR LENG
TH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC ® SEWER❑ / NEW EXISTING19
PLUMBING IN STRUCTURE? YES & NO❑ If yes,attach completed WaterAdeguacy Form
PERIMETERROUNDATION DRAINS PROPOSED? YESX NOD EXISTING SQ.FT.SO U-
EXISTING BEDROOMS PROPOSED BEDROOMS . 'Z TOTAL BEDROOMS_�2_—
OWNER acknowledges that submission of inaccurate Infonnadon may result in a slop work order or permit revocation.Acknowledgement of such Is by
signature below.I declare that I am the owner and I further dedare that I am entitled tolecl this permit and to do the work as proposed.I have
obtained permission from all the necessary pates,including any easement holder or parties of interest regarding this proiecl. The owner or least
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