HomeMy WebLinkAboutCOM2022-00030 Colocation on Existing Pole - BLD Application - 3/8/2022 MASON COUNTY COMMUNITY SERVICES Permit No: w 202L_000
PERMIT ASSISTANCE CENTER: R CC C C I\ �(—
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y e .BUILDING.PLANNING.PUBLIC HEALTH.FIRE MARSHAL L V C
=; 615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone 2U22
Bellaire(360)275-C467•Phone Elms:(360)482-5269 APR 2 2
BUILDING PERMIT APPLICATION
Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:s A J Joh.a1 LLc NAME:TBD
MAILING ADDRESS:POO-4ee MAILING ADDRESS:
CITY:Bww STATE:wA ZIP:1152E CITY: STATE: ZIP:
PHONE#1: PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: L&I REG# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑�
CM NAME EMAIL bdm @mpiW,M9...,A—
MAILINGADDRESS 21044eA.E.SW.zoz CITY O`oD STATE wA ZIP9e5a
PHONE 9714/""' CELL s°
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Q PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 1232134=30 ZONING x
JLEGAL DESCRIPTION(Abbreviated) TR3 of se sw s 28/iD6 PCL 1 BLAA01.14 BLAY03114(R)A"177Bwz FIRE DISTRICT
rr� SITE ADDRESS MILEPOST27$,5TATEWN3 CITY BELFAIR
DIRECTIONS TO SITE ADDRESS
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: (Checkanthat apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ ALTERATION❑ REPAIR❑ OTHER Q cOLac -N ON EwsT.POLE
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.)unuTr
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS wA NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Pa rlsjojB1dg)❑ NO❑
DESCRIBE WORK Eliglbk Faditl.R.q-d far tM hdmftla of(3)new..to—.Rh aridlary equipment an an edatkV manpde,and aoodatW ground equipment wNgn a Mnpe—V ouM.
SQUARE FOOTAGE: (proposed)
1 ST FLOOR" sq.ft. 2ND FLOOR wA sq.ft. 3RD FLOOR wA sq.ft. BASEMENT wA sq.ft.
DECK" sq.ft. COVERED DECK w" sq.ft. STORAGE" sq.ft. OTHER 35(1a11G pid) 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 permitlapplication 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)
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X D Brandon Clower a"""'""'""° ""a`° 03/08/22
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH