HomeMy WebLinkAboutBLD2023-01421 - BLD CD Environmental Health Review - 11/22/2023 Owe
MASON COUNTY COMMUNITY SERVICES Permit No: YA
PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL I V E D @�
615 W.Alder Street,Shelton,WA N584
Phone She4on:(3W)427-9670 ext.352•Fax:(350)427-7798 Phone
BeHalr.(360)275M6]•Phone ENna:(360)482-5269
OCT 16 2023 2L Noll
BUILDING PERMIT APPLICATAP"Ider
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:4ohanre Long NAME: ti
MAILING ADDRESS:131 E.OMaN l"ae MAILING ADDRESS: 9�
CITY:Shelton STATE:WA ZIP:ee5e4 CITY: STATE: ZIP:
PHONE#1:510-751-aeaa PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: w a h4 64TIE l ,A L&I REG#
PRIMARY CONTACT: OWNER p CONTRACTOR[I OTHER
NAME EMAIL
MAILING ADDRESS CITY STATE_ -
PHONE CELL cl-
PARCEL INFORMATION: `r
PARCELNUMBER(12 Digit Number) 32021-51 ZONINGRR5
LEGAL DESCRIPTION(Abbreviated) Slashoent Add Report 80e I La 125 T.L. FIRE DISTRICT
SITE ADDRESS 131 E DrclrerE lane CITY Sheibn
DIRECTIONS TO SITE ADDRESS Take Hvry3MEAg& M-Fdbw EAgNe Rd MAgate Store-Tease RlOHTonECreelww Dr-Fdb E
Crestview Or to E Parkway Blvd,lake a LEFT-Fogow E Paarwrry BWd,II mmmee E OrcMN lane-131 will as on the LEFT
IS THE PROJECT WITHIN 300 FF OF SLOPES)GREATER THAN 14%: YES[] NO E) SNOW LOAD:2�sf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (ChecAaetemapptV
SALTW ATER Q LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW ❑ ADDITION❑ ALTERATION[]+ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Re+tdence.Garage.Commercial Bldg.Erc.)Rseltlenee
IS USE: PRIMARY E SEASONAL❑ NUMBER OF BEDROOMS 1 NUMBER OF BATHROOMS 1
HEATED STRUCTURE? YES(Whale Bldg)0 YES(Pan(s/aJ6ldg)❑ NO❑
DESCRIBE WORK A°a a t0a af.Lan m mgh cellhg bedtaom
SOUARE FOOTAGE: (PrB cs4
1ST FLOOR sq.R. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER 10A sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: e4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE_MODEL YEAR _LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC El SEWER[] / NEW[I EXISTING
PLUMBING IN STRUCTURE? YES❑ NO[I Ijyes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NO[] EXISTING SQ.FT.
EXISTING BEDROOMS 1 PROPOSED BEDROOMS 0 TOTAL BEDROOMS 1
OWNER ackno su dges Net submission of Inaccurate Information may result in a atop wotk order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the O vnOl and I further declare mat I an entitled to receive this permit and to do the vork as proposed.I have
- Obtained permission from all the necessary parties,including any easement holder or parlles of interest regardlrlg 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 st,alure(a)for review and inspection. This pelmitlappiication becomes null It void If work or authorized construction re not commenced motion 180
days or if construction work Is suspended for a pedod of IN 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
X 1o/1t,/a;
natu of OWNER he OWNERI Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH �.21
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