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Home My WebLink AboutGRD2008-00002 Stump and Grade Existing Area - GRD Application - 4/2/2008 FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD PERMIT NO.: GIRD MASON COUNTY LAND MODIFICATION PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner 14/a. 4,61,j,ktss At-cc_ (t-F Contractor Name Mailinn Address —J Vz-xo Awr KIIiJ Mailing Addre s 12! ye C4 / N City. ( t' !K State LNI Zip Code 10 u City 4 % State lc 1 Zip Code S Phone( .; ) - LJe Other Ph. Z( S3 ) 4 i 3-oo Z 51 Ph. Z ray-y,z„, Other Ph.( Z_ Lien/Title Holdex aOE l4-5vq/X_e:%, Contractor Reg. # Address J 6. Expiration ENGINEER INFORMATION Name i Phone T Address State ZR Zip Code PARCEL INFORMATION-12 digit Tax Parcel No. i o SY / D C% / 000C. Fire District Af,, Legal Description Site Address(include street name and city 77 t) N e hFi L% C S c e LAI Directions to site: 2 ..c'n #`osT --.- V,:Y-e :«� ri (l3cyc 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 Runoff Stream ✓Slopes or Bluffs ✓ Soft compressible soils TYPE OF JOB - Excavation Filling Grading Total size of area 46:AC,n---S Size of area to be cleared on slopes over 10% Estimated amount of cubic yards Describe Work IZemL.ye 5r14ii!j! s Ce2L r 4,2r-/�- LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes, source ❑ Will excavated materials be taken off site? If yes, destination ❑ Does fill contain potential hazardous materials? ❑ Has a soils report been completed on site? If yes, include copy. 4 , ❑ Will proposal result in redirection of any surface water runoff onto adjacent properties? ❑ Gr", Will proposed work alter where storm water or ground water enters or exits the site? 0 Will quality, quantity or velocity of storm/ground water be altered? 13 Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? U 0 Will the land be replanted upon completion? ❑ Will the proposal result in slopes steeper than those currently on site? Is the site within 200' of a designated shoreline? NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,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 of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall first obtaini approval be e without first optaining appfc- S Date�( 41 X /� Date 1 c FOR OFFICIAL USE BEYOND THIS POINT Accepted b � Date a_l�C Submittal Amount Due Receipt No. T DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Planning Department Public Works Department Fire Marshal FEES Grading Permit Fee Site Inspection Plan Review Fee Other Public Works Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES ell PERMIT NO.: GRD MASON COUNTY LAND MODIFICATION PERMIT APPLICATION 0000 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275- 467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner Wig. Q.EruR lss ar•Cc F4kj rt.r Contractor Name .5 F(. r- Mailing Add r ss ! ` Avev Mailing Address City State WA ZipCodelk_31-4 City l State !- Zip Code Phone( S3) 19 t/o Other Ph. 2 IS Z m-Gwz p Ph.(_) Other Ph.( )�';i� --Z/ <; Lien/Title HoldeL Dt3or Contractor Reg. # Address J Expiration ENGINEER INFORMATION Name _ Phoneh Address State Zip Code PARCEL INFORMATION-12 digit Tax Parcel No. /2 So J- / o o / 0004 0 Fire District ArAeo, Legal Description Site Address(include street name and city 770 NC 14o LW Directions to site: it, / Aeig j r►a. yt- rJ4'6 A,1- f7,� ^� , 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/Creeks Pond Wetland Seasonal Runoff StreamJCSlopes or Bluffs__Z Soft compressible soils TYPE OF JOB -Excavation Filling Grading Total size of area 4XAC/RCS Size of area to be cleared on slopes over 10% Estimated,amount of cubic yards Describe Work &AAavE STUwJEs 2e1-,1.L_ 6.rri A$ZJ (��Z �x�sri�vy L.eyeL A,te& LAND MODIFICATION INFORMATION YES NO Will fill be brought on site? If yes, source Will excavated materials be taken off site? If yes, destination Does fill contain potential hazardous materials? Has a soils report been completed on site? If yes, include copy. 13 0 Will proposal result in redirection of any surface water runoff onto adjacent properties? 13 1111,001 Will proposed work alter where storm water or ground water enters or exits the site? 1 Will quality, quantity or velocity of storm/ground water be altered? 13 Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? W o Will the land be replanted upon completion? E� Will the proposal result in slopes steeper than those currently on site? 13 Is the site within 200' of a designated shoreline? NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,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 of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a the Contractor Registration Law RCW 18.27 and am aware of the contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and that all work ordinance requirements regulating the work for which this permit is issued will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall first obtaini approval. be made without first taining appwyaL X - Date i i;� X {�� Date — Z !1 /� FOR OFFICIAL USE BEYOND THIS POINT Accepted by6A�41 I Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Planning Department Public Works Department Fire Marshal FEES Grading Permit Fee Site Inspection Plan Review Fee Other Public Works Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES RECEIVED Jul 9 : 2008 MASON COUNTY 1923767 MASON CO WA 07/09/2008 12:53 PM COV WA RENAISSANCE FAIRE #20978 Rec Fee. $43.00 Pages: 2 IIIIII IN 11111111111111 I111111 III 1111111111111111111 IN RETURN ADDRESS GRANTOR(S) (Last, First and Middle Initial) 40h t2{NA iS51h-UCC- 6�I�// ��vA REND)SS/4 Nc� (`�tiVvris� i 11 1 N C C4 a � Y1rc�t!Z . [,lJif y 7 Z y GRANTEE; MASON COUNTY DEPARTMENT OF PUBLIC WORKS DECLARATION OF COVENANTS ASSOCIATED WITH PRIVATELY MAINTAINED STORM DRAINAGE FACILITIES THE Declaration of Covenant 'ro BE KEPT 1N� C'LC pW(;E r In consideration of approval of the development known as WA .2�n►e,ctA,iJ�p > �.¢ , relating to real prope y described as follows: County Assessor's Property Tax Parcel Number /23 v 80 0 a0e-,o O The undersigned, as owner(s), covenant and agree that: SLR- JS T-V- 1, S0%r 2-3 9"8- 1. If at any time Mason County reasonably determines that maintenance or repair work is required to be done to the existing,approved storm drainage facilities installed on the property described above and located outside of any public right-of-way (which will mean repair and or clean out of the existing system only to the same standards as originally installed and approved), the Director of the Department of Public Works shall give the current owners seven days notice that the County intends to perform such maintenance or repairs, or to have them performed by others. If the current owners have not completed or are not diligently pursuing the repair or maintenance of the system and it becomes necessary for Mason County to perform the work,the current owners will assume responsibility for the cost of such maintenance or repair and will reimburse the County within thirty days of receipt of the invoice.Overdue payments will require payment of interest at the current legal rate for liquidated judgments, and any costs or fees incurred by the County, should any legal action be required to collect such payments, will be borne by the parties responsible for said reimbursements. 2. If at any time Mason County reasonably determines that the existing and approved storm drainage system on the property poses a hazard to life and limb, or endangers property, or adversely affects the safety and operations of a public way, due to failure, damage or non-maintenance of the existing on-site storm system, and that the situation is so adverse as to preclude written notice to said owners,the Director of the Department of Public Works may take the measures necessary to eliminate the hazardous situation(which will mean repair or clean out of the existing system only to the same standards as originally installed and approved)provided the Director has first made a reasonable effort to locate said owner before acting. The current owners will assume responsibility for the cost of such maintenance or repair;and will reimburse the County within thirty days of receipt of the invoice.Overdue payments will require payment of interest at the current legal rate for liquidated judgments,and any costs or fees incurred by the County, should any be borne by the parties responsible for said reimbursements. 3.The owner shall keep the Mason County Public Works Department informed at all times as to the name, address and telephone number of the contact person responsible for the performance of maintenance or repair work to the storm drainage facilities. These covenants are intended to protect the value and desirability of the real property described above,and to benefit all the citizens of Mason County.They shall run with the land and be binding on all parties having or acquiring from the current owners or their successors,any right,title or interest therein, and to the benefit of all the citizens of Mason County. Signature Signature Cz'-7-y Owner Owner /`1 y e Address Address City, State,Zip City, State, Zip Phone: 2S3 �'&Y-V Z./Q Phone: STATE OF WASHINGTON, SS. (INDIVIDUAL ACKNOWLEDGEMENT) County of MASON 1, V'40',t M PKIS ,Notary Public in and for the State of Washington, residing at I ACV* A-t tr,4 ,do hereby certify that on this q t I day of Jv( ,20 03,personally appeared before me R111VAlyd G l F v4�� to me known to be the individual Z"described in and who executed the within instrument and acknowledged that H f- signed and sealed the same as (S free and voluntary act and deed for the uses and purposes herein mentioned. GIVEN UNDER MY HAND AND OFFICIAL SEAL this 'I day of ul s , 20 09 Notary Public in and for the State of Washington,residing at 7Ac-.o�^R in said County. My Commission expires VICTOR M. PIRES Notary Public State of Washington My Commission Expires ril 1 2012