HomeMy WebLinkAboutGRD2013-00003 Cancelled - GRD Application - 2/15/2013 FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT NO.: GRD 60y
-6�((- )
�., MASON COUNTY _
FE8 28 2LAND MODIFICATION PERMIT APPLICATION —AL ),A v -
426 W.Cedar/P.O.Box 186,Shelton,WA 98684
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICA,NT INFORMATION CONTRACTOR INFORMATION
Owner &D&MI Contractor Name
Mailing Address W -• Mailing Address
CitytrJCyipaq State 4VA Zip Code S � City State Zip Code
Phone(, 2 _ 3 ther Ph.( Ph.( Other Ph.(�
Lien/Title Holder Contractor Reg. #
Address Expiration / /
ENGINEER INFORMATION ,��,, `
Name ' E'1j Phone � 2-
Address C State UU Zip ode
PARCEL INFORMATION-12 digit Tax Parcel No.12ta Ito /15 �xji Fire District
Legal Description
Site Address(include street name and city 6 A
Directions to site: /41l t
e F l'&J — 4
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Ru ff Stream Slopes or
Bluffs Soft compressible soils
TYPE OF JOB - Excavation_5<_' Filling Grading Totals' e o rea '7. nr`io S6
Size of area to be cleared on slopes over 10% ti to amou(�t f cuubi yar
Describe Work Ems✓ P " t Ki K
LAND MODIFICATION INFORMATION ` �, '1a YES NO
WIII fill be brought on site. If yes, source/45 ale'e, \�
Will excavated materials be taken off site? If yes, des ' ation �—
Does fill contain potential hazardous materials? 0
Has a soils report been completed on site? If yes, i Iude copy. 0
Will proposal result in redirection of any surface w er runoff to ayd
ent properties? E
13
Will proposed work alter where storm water or gr and water r its the site?
Will quality, quantity or velocity of storm/groun ater a alt ed. � 0
Will runoff be collected/controlled by intercept , c rt i ral s or other collection devices? A, 13
Will the land be replanted upon completion? 1
Will the proposal result in slopes steepe th n th se u re ion site? 0
Is the site within 200' of a designated Srhor line?
NOTICE: THIS PERM7=d
OMES NULL VO IF WORK OR ON RUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WOUSPENDED OR ANDONED FORA-PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUOF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information providedrate and gran employees of Mason County access to the above described property and structures for review and
inspection of this procknowledgm t of such is by signature below:
OWNER AFFIDAVIT-1 hat I am ex pt from the requirements of CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
the Contractor Registra RCW 1 7 and am aware of the contractor in the State of Washington and that I am aware of the
ordinance isich this p rmit is issued and that all work ordinance requirements regulating the work for which this permit is issued
will be ne in confor rewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first fining app Val be made without first obtaining approval.
Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted b Dat Submittal Amount Due Receipt No.
DEP R TAL REVIEW APPROVED DENIED CONDITION CODES
Building De rt nt
Planning Depa ment
4-o A IA C)
Public Work Department
Fire Marsh -
FEES
Grading Permit Fee Site Inspection
Plan Review Fee Other
Public or Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES