HomeMy WebLinkAboutCOM2022-00015 Wireless Telecommunication Tower - COM Application - 4/5/2022 ATC 310511
12949795 MASON COUNTY COMMUNITY SERVICES Permit No: O -joW o J'
PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL RECEIVED
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax:(380)427-7798 Phone
Belfalr.(360)275-4467•Phone Elms:(360)482-5269 APR 0 5
2021
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMARX W. Alder treet
NAME: EINO I KUKI NAME: TBD
MAILING ADDRESS: 24763 NE SR-3 MAILING ADDRESS:
CITY: BELFAIR $_TATE: wA ZIP.9852e CITY: STATE: ZIP:
PHONE#1: N/A PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: N/A L&I REG# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑x
NAME Vinh Dinh-Infinigy on behalf of ATC and T-Mobile EMAIL VW&ctr9&jaftlWom
MAILINGADDRESS•21806 Poplar Way CITY Brier STATE WA ZIP 98036
PHONE CELL (206)295.5926
PARCEL INFORMATION: G
PARCEL NUMBER(12 Digit Number)�3�-2�---1(7��(� ZONING RROs
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS 24765 NE SR-3 CITY BELFAIR,WA 98528
DIRECTIONS TO SITE ADDRESS refer to project drawing plan
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO® SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Chock ail aw pply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION® REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage.Co n nerciaf Bldg,Etc.)Wireless telecommunication tower/facility
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS n/a NUMBER OF BATHROOMS n/a
HEATED STRUCTURE? YES(whole Bldg)❑ YES(Part[sif ojBfdg)❑ NO Pq
DESCRIBE WORK Refer to drawing plan for SOW
SQUARE FOOTAGE:(Proposed)
IST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.& STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT 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:
SEWAGEISEWER SOURCE: SEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO® Ifyes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NO[-] EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS
OWNER acknowledges that submission of Inaccurate Information may result In a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding 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 structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period 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)
X **See Letter of Authorization
Signature of TOWER OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED I DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH