HomeMy WebLinkAboutGRD2007-00026 - GRD Application - 9/17/2007 FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD PERMIT NO.: GR -
MASON COUNTY
LAND MODIFICATION PERMIT APPLICATION Y`
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Etma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMA ION'Jr i CONTRACTOR INFORMATION
Owner 4P I Contractor Name
Mailing Address ' S .s- Mailing Address _
City Qc'/-., , State _*(-Zip Code d City ' i S a e t o Zip Code
Phone( ?i E-) ! - ;?,�a30ther Ph.( Ph. �� e!/ 7 � her Ph. �.�
Lien/Title Holder Contractor Reg. # �r-rt,°79 7f 03
Address Expiration
ENGINEER JkFORMATIQN
Name C C�iaSr,� Ott z� Phone ( 2� ) 6 — �L&
Address /r' •- � � State 10 - Zip C_ode
PARCEL INFORMATION-12 digit Tad Parcel No. !` / > ire District
Legal Description 7 ' G - �C7 "
Site Address(include street name arfd city Cx
Directions to site: / t ci•
jv:-bt
Will timlier be ut an sold in parcel preparation? (Yes/No) A;
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 — — t T
TYPE OF JOB - Excavation Filling Grading Total size of area
Size of area to be cleared�on slopes ove -1 — Estimated,am unt of,cubic yards
Describe Work F t/ t _
1 ! e- / C I
LAND MODIFICATION INFORMATION YES NO
Will fill be brought on site? If yes, source ❑ iler-
Will excavated materials e taken
at rlals b t k n 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? -*t� ❑
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-1 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 obtaining approval. be ma e without first obta ing approval.
I �
c Date 9 1• Date��/ �
FOR OFFICIAL USE BEYOND HIS POINT'
Accepted by a Date`1-11,C[I Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Department RECEBMD
Planning Department SEP 1
Public Works Department
MASON , ?l
Fire Marshal
FEES
Grading Permit Fee Site Inspection
Plan Review Fee Other
Public Works Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES
5E910N 21,TOWN5HIP 23 NOKTH, RANGE I WEST,W.M.
I 16 15
\ -- 22 ---'" LEGEND
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OITCH INLET
\ \ \•• �,\ 111 I 1 MANHOLE Qa
RISER
DITCH(DIRECTION OF FLMV) 7-
STORM PIPE
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GENERAL NOTES:
-` IDENTIF'TREES ON-SITE DUFJNG CONSTRUCTION TO REMAIN.
PROTECT PER
2)11i5TALl ME MATTIeiG ON AAL EY.POSED SOILS AT SLOPES Of 2
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NO. =.A. C�. APPR. RFv15�.p. JOB No.: 0072C6 AS 5110"
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