HomeMy WebLinkAboutBLD2024-00286 - BLD CD Environmental Health Review - 4/5/2024 PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:Mike Randich NAME:
MAILING ADDRESS:1222 Friedlander Or MAILING ADDRESS:
PHONC=:Aberdleem
#I:W STATE:'A'^ ZIP: 2 CITY: 9 LTS:
PHONE#1: 60 5383524 PHONE: tC vur(U
PHONE#2:as0 sso-alas EMAIL
E21.IAE,:mmndich(alcomcast.net L&I REG# I I
PRIMARY CONTACT: OWNER p CONTRACTOR❑ OTHER
NAMES FUMa' EMA mrendich@aamcastnst
MAILING ADDRESS 1222 Friedlander Dr CI STATE Wn 98520
PHONE swssasei< CELL a--1`ie v ClJ
PARCEL INFORMATION:
PARCEL NUMBER.(12 Digit Number) 220055100005 qA�� F -5 2024
LEGAL DESCRIPTION(Abbreviated) Tracts 5 of Phillips Lake M2 OA w..GDrTG1TRI�1�L�e
SITE ADDRESS750 East Phillips Lake loop Rd F CITY
DB2ECTIONS TO STTE ADDRESS —""-"'--n"".".".."."..a
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YESO+ NO❑ SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (chink otl min aypty):
SALTWATER❑ LAKE Qi RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM
TYPE OF WORK: NEW 0 ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Rs idence,Garage.Commercial Bldg,Erc)Resideneal
IS USE: PRIMARY❑ SEASONAL 0+ NUMBER OF BEDROOMS 2 NUMBER OF BATHROOMS t
DATED STRUCTURE? YES(whole Bldg)EI YES(Pm-gs]ofBldg)❑ NO❑
DESCRIBE WORKNew Build
SOUARE FOOTAGE: ils yared/ _
1ST FLOOR9W sq.fL 2ND FLOOR sq.ft. 3RD FLOOR sq.fl. BASEMENT sq.ft.
DECK sq.R COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUDIED* r
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH: �
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW 0+ EXISTING❑
PLUMBING IN STRUCTURE? YES Q+ NO lfyes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YESX/ NOD EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS Z TOTAL BEDROOMS 2 11
OWNER acknowledges that submission of insoarate irdormabon may result in a stop work order or permit rewcallon.AcknoMledgement of such is by
signature below.I declare Sal I am the owner and I further declare that I am entibed to receive this permit and N 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 intonation provided Is accurate and grants employees of Mason County access to the above desalbed property
and sbucture(s)for review and inspection. This pennit'appiicabon becomes null&void if work or authorized 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 CODE 14.08.42)
X 3/1/2024
Signature of OWNER(Must be started by the OWNER) Date
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