HomeMy WebLinkAboutBLD2017-00556 SFR - BLD Application - 6/19/2017 A�oft ooP MASON COUNTY COMMUNITY SERVICES
PERMIT ASSISTANCE CENTER: Permit No:
?:,•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584 RECEIVED
f
I Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
834 Belfair.(360)275-4467•Phone Elma:(360)482-5269 SUN 19 2017
BUILDING BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAMOAq--k A- Sq., JJ�n a NAMENOI `� 5�'�rf,
MAILING ADDRESS: Y19 -aA AVI-AJL MAILING ADDRESS: 91 W CT
CITY: ` ,f L).t STATE: t& ZIP: 1-74SD CITY: (18_`&<P STATE:-W-,' IP: gyir2Y
PHONE#1: R 71 7? Jf4T. PHONE: CELL: 070o_31 3 �'wk
PHONE#2: EMAIL : S G/l rr� �c+ice ��•�I •Ldv`�
EMAIL: okr So I ,t( . ¢ L&I REG# 0 S C, EXP.: /_/10 I
PRIMARY CONTACT: OWNER❑ CONTRACTORUL OTHER
NAME s n Ise"., EMAIL Aan 'n4"4L�iA 4��, (�dV►t
MAILING ADDRESS PciLa-i CT CITY Va F'a;r STATE_. _ ZIP t1 Z
PHONE CELL a6()r79
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 1 &lad •%51 • QW Z I ZONING
LEGAL DESCRIPTION(Abbreviated) FI DISTRIC
SITE ADDRESS 7i V I F OU ��n (/E��.. �( CITY It y A
DIRECTIONS TO SITE ADDRESS 1 y� ,,,�� �� (�cR(c„n cl {�,�, 'r�,.-,� t2-44
0:/___ (''`,Sty. tit A �4rd!L'
1S THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NOt
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 ❑ ALT(EERATION ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.)
IS USE: PRIMARY RJ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS Z
HEATED STRUCTURE? YES(Whole Bldo ❑ YES(Part(sj of Bldg) ❑ NO ❑
DESCRIBE WORK Q c L( h L Q
S UARE FOOTAGE: (propose+existing)
L
I sq.ft. 2ND FLOOR sq. ft. 3RD FLOOR sq.ft. BASEMENT sq. ft.
s COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTU + + NFORMATION: F THE FLOOR P�LANREQUIRED*
MAKE MODEL YEAR L
W H BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE. SEPTIC ElSEWER) / NEW EXISTING❑
PLUMBING IN STRUCTURE? YES ❑ NO❑ If yes, attach completed Water Adequacy Form
PERIMETER(FOUNDATION 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 permittapplication becomes null&void if work or authorized construction is not commenced within 180
days or if construction-work-is.suspended tor-a-period-nf 180 days.
PROOF F CONTINUATI OF WORK ON TH PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
IT APPLICATION F 180 DAYS OF MOR -WILL—CAUSE THE APPLICATION TO BE EXPIRED. (MASON
COUNTY CODE 14 08.42)
d
Signature of OWNER(Must be signed by the OWNER) Date
D ARTME REVIEW APPRO 'D DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPART 7-26-
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH