HomeMy WebLinkAboutCOM2022-00045 Cell Tower - COM Application - 10/19/2022 DocuSign Envelope ID:8732AAF5-98E1-4FEC-BCFO-5289AB662EAF m ��_���
MASON COUNTY COMMUNITY SERVICES Permit No: O
PERMIT ASSISTANCE CENTER: RECEIVED
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext 352•Fax:(360)427-7798 Phone ��
Beltair.(360)275-0467•Phone Elma:(360)482-5269 2022
BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: r Street
NAME: Green Diamond Resource Company NAME: TBD
MAILING ADDRESS: 215 North Third Street MAILING ADDRESS:
CITY: Shelton STATE: WA ZIP: CITY: STATE: ZIP:
PHONE#l: 360.427.4796 PHONE: CELL:
PHONE#2: EMAIL:
EMAIL: cmarbet@greendiamond.com L&I REG# E)P.
PRIMARY CONTACT: OWNER❑ CONTRACTOR 4 OTHER
NAME Bill No -North Grou EMAIL Oillnorth@northgroup,net
MAILING ADD SS P Box 44 CITY Snohomish STATE-WA _ZIP 98291
PHONE 5-87 -2909 CELL same
PARCEL INFORMATION: Z
PARCEL NUMBER(12 Digit Number) 32133-41-00000 ZONING Rur esidentia120 s
LEGAL DESCRIPTION(Abbreviated) 1.2 6rp18-23 A2100328 PTN OF SE LYING FIRE DISTRICT 5
SITE ADDRESS XXX E.McEWAN PRAIRIE RD., CITY Shelton WA 98584
DIRECTIONS TO SITE ADDRESS on US-101 N 15.3 mi.Take the Wallace Kneeland Blvd exit 0.3 mi,Turn right onto W Wallace Blvd 289 ft,
Continue straight onto Wallace Kneeland Blvd 0.8 mi,Turn left onto E Brockdale Rd 1.7 mi,Turn right onto E McEwan Prairie Rd Destination will be on the right 23 m. ^
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO® SNOW LOAD: N A sf L
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that appiy):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW® ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Ex.) Wireless Communications Facility
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS N/A NUMBER OF BATHROOMS N/A
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Parifs)ojBidg)❑ NO 29
DESCRIBE WORK a newly constructed 150'self-support tower designed for 3 users with attached antennas and ground
SQUARE FOOTAGE:(proposed)
1ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER 3600 sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE N/A MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE:N/ASEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO® If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES❑ NO® EXISTING SQ.FT.
EXISTING BEDROOMS N/A PROPOSED BEDROOMS N/A TOTAL BEDROOMS N/A
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 dedare that 1 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 prqvided 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 `, 02/08/2022
t 1 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