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Home My WebLink AboutGRD2007-00019 - GRD Application - 7/26/2007 PERMIT NO.: GIRD 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 Owner ~,C A 1` . V-izC(o lil; Contractor Name , k fey QLA Ccvt�' Mailing Address V.0 , X Mailing Address �Pc oX 1114t City -4 4: +/Z- State VVIr- Zi Code 6 ,L n City State WA Zip Code 1 Phone( I.'l Other Ph. :2;1—Ii0 i Ph.0 " Other Ph.( )-731-71 )I Lien/Title Holder 01 f> Contractor Reg. # SCI Address Expiration ENGINEER INFORMATION /► Name �;1 A Phone �) Address State Zip Code PARCEL INFORMATION-12 digit Tax Parcel No. 3 Z SO / OW Fire District Legal Description IV. yL `�. V) LA 4 .5^ 0�,TV" k14 �Gr � ,Plak V t.R� 20, t46S, �W Site Address(include street nap nd city Directions to site: 3A +SAC .*a C7r Will timbe. )e cut and sold in parcel preparation? (Yes/No) Is your prol,.erty within 200' of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Soft compressible soils TYPE OF JOB - Excavation Filling Gradin9 Total size of area Size of area to b cleared orl slopes over 10% RM Estimated amount of cubic yards d55 S Describe Work -ate 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? ❑ ❑ r Will quality, quantity or velocity of storm/ground water be altered? ❑ ❑ Will runoff be collected/controlled by interceptors, curtain drains or other collection devices? ❑ ❑ 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? ❑ R 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-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. L be made without first obtaining approval. X Date --�6 _ "--� X if/! Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by,____ %A 11\ Date Submittal Amount Due Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES Building Department Planning Department Public Works Department Fire Marshal FETS Grading Permit Fee , L7," /ZitoWspection Plan Review Fee Other Public b1/ors Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES