HomeMy WebLinkAboutGRD92-0018 - GRD Permit / Conditions - 3/12/1995 MASON COUNTY
Mason County Bldg. 111 426 W. Cedar PERMIT
P.O. Box 186 Shelton, Washington 98584 NULL VPID BY EXPIRATION
DATE BY
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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date by
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by date by
te V date
NAILING b
date by e y
Water Line FINAL INSPECTION
date by date by date by
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MASON cou= aO��
LAND MODIFICATION PERMIT 6,' ')EL
Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562 -5628
PLEASE PRINT
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#1 Owners A. (2 • T11 y n n j Phcnek 1_6 o -nyy -2 S 9' V
Site Address T CA-W L.ti�� Ci ty _E�L.,Ly IL, _StL."&Zip
Owner'-Address R e • ;�6 x � _ � Ci St
ty_,�A�<E 6 i4 Yr�Y �Zip�
Describe Work Frziz eApL_ �, ,-i g„r,_
#2 Contractor NameJAt5 art nc (r,��r�r�„_T, ft,1 Contractor Reg#,40- 5,3 -►Z6-2�3cw
Address , ►,, L`r-►� Expiration date
Ci ty. StZip_Phone
#3 Engineer's Nam Phone#
Address Ci ty St Zip_
#4 Parcel No. '2-L-.- "3Cf e
Legal Description__
#5 Number of cubic yards to be excavated:
Number of cubic yards to be filled:
Number of cubic yards to be graded:
#6 Will this be a balanced cut and fill entirely within the site?
Yes y No
If No: Will fill be brought on site? Yes No
Where does imported fill originate from?
Does fill contain any potentially hazardous materials?
Yes No
#7 Will excavated materials be taken off site? Yes No
If Yes: Where will excavated materials be taken?
#8 Briefly describe existing terrain, vegetation, and improvements on
subject site? 9 tc-1
#9 Has a soils report been completed on the subject site? M 0
If yes, include copy with application.
#10 Does the subject site contain any of the following features?
River Lake Wetlands Sal twa ter
Slope greater than 15t Soft compressible soils
Seasonal Runoff None
#21 Will the proposed land surface modification change the points
where storm crater or groundwater enters or exits the site?
#12 Will the proposed land surface modification change the quality,
quantity, or velocity of storm wa ter/groundwa ter? t'
#13 Is tre sabject site within 200 feet of a designated shoreline?
#14 Whaf methods, if any, will be utilized to minimize erosion and
possible sedimentation into nearby waters? SN lur 94Z L".
#15 Will this land modification result in the redirection of any surface
water_ runoff onto adjacent properties? N(-, _
#16 Wilk*-*-&.--face or subsurface runoff be collected or controlled by
interceptors, curtain drains, or other water collection devices
once this land modification has been completed? `lt
#17 Will the land be replanted upon completion? �c
If yes, with what types of plants? S J4 2 0 Gs - r iz _S - "T9->=
#18 What are the lengths and heights of slopes currently existing on
the site? ._3 ra -j 7 C Pt-/-�-N
#19 Will this modification result in slopes steeper than those currently
on the site? n If so, how steep?
Show following on the site plan Directions to job site
Lot Dimensions Flood Zones
Existing Structures Fences A LJ-Y A,
Structure Setbacks Driveways
Wa ter Lines Shorelines
Drainage Plan Topography
Septic Systems Wells SS &wCC-- 1
Proposed Improvements Easements
Name of Flanking Street 12_p 1 �3Z 1
Name of Fronting Street
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Scale:
Date:
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NOTICE: THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK-
IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER WORK
IS COMMENCED
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR
CONTRACTORS REGISTRATION LAW RCW 18.27 , AND AM AWARE IN THE STATE OF WISHINGTON AND I AM AWARE OF THE
OF THE MASON GOUNTY ORDINANCE REQUIREMENTS FOR WHICH ORDINANCE REQUIREMENTS REGULATING THE WORK FOR WHICH
THIS PERMIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE
WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING
DEPARTMENT. DEPARTMENT.
X OWNER X BY
DATE -t. I�l�l Z, DATE
Return permit to: Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, SPA 98584 427-9670/1-800-562-51
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEP-A-R-TMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond
Approvat
Planning:
Environmental Health:
Building Plan Review:
Fire Marshall :
Other:
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APPLICANT TO DRAW SITE PLAN BELO
TO DRAW TOPOGRAPHY PROFILE BELOW
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