HomeMy WebLinkAboutGRD2007-00027 - GRD Application - 9/17/2007 FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD PERMIT NO.: GRID ZOO
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
OwnerLr / T ,; — �E'n�Zrsl� f' lU Contractor Name P
Mailing Address `� Mailing Address
City wi-emir— State W ArZip Code City ' C ` i State 1\, ,AV Zip Code '7Tn
Phone(: )3't/ 7So Other Ph.L____) Other Ph.
Lien/Title Holder�)c�tic`— Contractor Reg. # J, E�et!j 36 95
Address Expiration_ / i" / Occ,_.
ENGINEER INFORMAkTION
Name Orr Phone
Address 16c,I "��'r "' Oi f, -( State Zip Code 1
- c
PARCEL INFORMATION-12 digit Tax Parcel N v?3 �?f / _/ Fire District
Legal Description /40 X 0) _
Site Address(include street narhe and city ,C r 4
Directions to site: TT— _��' fc� �7„�t�' �• ctC
tn/� c-
Will ftfnber be cut and sold in parcel preparation? (Yes/No)&M
Is your property within 200' of the following: Body of Wat�UName) !— 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
Size of area to be cleared on slopes over 10% Estimated amount of cubic yards
Describe Work CLL6 4" '.7/7 1 % •� , �',/ '�i'e
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. ❑
Will proposal result in redirection of any surface water runoff onto adjacent properties? ❑ (•
Will proposed work alter where storm water or ground water enters or exits the site? ❑ •�
Will quality, quantity or velocity of storm/ground water be altered?
Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? IlEk ❑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-1 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 obt ning approval. 7 be made without first obtaining approval.
.rW —A Date /`� "J Y Date
FOR OFFICIAL USE BEYON THIS POI T
Accepted by DateCi-l1 0!1 Submittal Amount Due Receipt No.
DE AR MENTAL REVIEW APPROVED DENIED CONDITION CODES
Building D&Wment
Planning Department RECEIVED
Public Works Department SEP 1 7 2007
Fire Marshal [MASON COUNTY
FEES
Grading Permit Fee Site Inspection
Plan Review Fee Other
Public Works Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES
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