HomeMy WebLinkAboutBLD CD Environmental Health Review - 7/15/2024 MASON COUNTY Permit No:bL9 a?ta?t ){��
COMMUNITY DEVELOPMENT
N VjR"NTiypg inter, Building,Planning r--I V E D
HEALOIALDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: .
lider Street
NAME:Leonard Sr Denise Anderson NAME: NA
MAILING ADDRESS:616 West Broadwal MAILING ADDRESS:
CITY:Montesano STATE: WA ZIP: CITY: STATE: ZIP:
PHONE#1: 360-590-2120 PHONE: CELL:
PHONE#2: EMAIL:
EMAIL:IeonardaOOlf(D.corncast.net L&I REG#
PRIMARY CONTACT: OWNER& CONTRACFOR❑ OTHER❑
NAME eonar n erson EMAIL
MAILING ADDRESS Rame - CITY STATE
PHONE CELL 3RQ_FQO_9190 J
PARCEL INFORMATION: Fip� It
PARCEL NUMBER(12 Digit Number) 61930-43-90062 ZONING
LEGAL DESCRIPTION(Abbreviated)LOT:2 Of SP#2518 PTN TR6 S12 BE S 17250 FIRE DISTRICT
SITE ADDRESS 51 W Benthain Road CITY Elma
DIRECTIONS TO SITE ADDRESS West on MaOock/Brady Rd.to Shafer Park Rd. left on Shafer Park Rd,to W Bentein Rd.
Left on W Benthein Rd.first driveway on left.
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%; YES® NO❑ SNOW LOAD: 25 nsf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Che ka0 tlw w1,,h
SALTWATER❑ LAKE❑ RIVEWCREEK® POND ❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW Q ADDITION ❑ ALTERATION❑ REPAIR❑ OTHER n
USE OF STRUCTURE(ee=maau,C�Cwwsen:W 111dg,ere.)
IS USE: PRIMARY® SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS_
HEATED STRUCTURE? YES({ tsar Bldg)❑ YES(Parr/s]afBidg)❑ NO❑
DESCRIBE WORK
SOUARE FOOTAGE: ti pared/
1ST FLOOR sq.iL 2ND FLOOR sq.ft. 3RD FLOOR sq.R BASEMENT sq.R
DECK sq.ft. COVERED DECK sq.R STORAGE sq.ft. OTHER sq.&
GARAGE864 sq.& Attached[] Detached CARPORT 432 sq.ft. Attached[] Detached®
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC® SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES ® NO❑ Ifyes,attach completed Water Adequacy Foray
PERWETER/FOUNDATION DRAINS PROPOSED? YES❑ NOW EXISTING SQ.FT. 0
EXISTING BEDROOMS 0 PROPOSED BEDROOMS TOTALEEDROOMS
OWNER acknowiedges that submission of inaccurate information may result in a step work order or permit revocation.AdmoWedgemenf of wall is by
signature below.I declare that I am the owner and I further declare that I am entitled to reeelve this pert and to do the work as proposed.I have
obtained!permission from all the necessary parties,including my easement holder or parties of interest regarding this prgecL The owner or legal
representative,represents that Me information provided is accurate end grants employees of Mason County access to the above described property
and slmcture(s)for review and inspection. This pems/applicatlon becomes null&void If work m authorized construction is not commenced within 180
days or a conswctim vrork is suspended for a penad 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)
Signature of OWNER(Must be sinned bvthe OWNER) Date
-DEPARTMENTAL REVIEW - APPROVED DATE-. DENIED DAM . 'TAGS/NOTES/CONDI'l'IONS'Y�-'=
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
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