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Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFORM TON CONTRACTOR INFORMATION Owner IQy P" Contractor NameC G GGS Mailin Ad ess — Mailing Address _ City State WR Zip Code 0 City _a State Zip Code O Phone(253) v IOther Ph.( Ph. - 5 Other Ph.4L'�t4 0 Lien/Title Holder Contractor Reg. # C,RDWNM4 Address Expiration SEPTIC/WATER SYSTEM INFORMATI N- onnect o Ne eptic Existing Septic Connect to Sewer Systems/Name of Sewer ystem =0WPw Well Water System��Name of Water System PARCEL INFORMATION- i it lax Parcel No. b / / pD Fire District Legal Description Y1 D t, . , LOT VIR. Site Address(Please in de stye t n e, street number�ndi ity) $ e D'rections to site .� o w. , Will ti be" be cut and sold in parcel preparation? (Ye o CVIGt , Is your property within 200' of the following: Body of Wa er(Name) N(7 Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs PERMANENT RESIDENCE❑ SEASONAL RESIDENCE❑ krdo New Add Alt Repair Other Use of Building k ms No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor Loft Basement Deck Other sq. ft. Att ched Detached Carport Attached Detached MO LE HOME INFORMATION-Make Model 4e, Model Year Length 516 Width 2$ Serial No. IK1 N . of Bedrooms 2- No. of Bathrooms Type of Heat �Y Purchase rice $ 1 00 Replacement Unit ?(DNo) Installer Name OroWyil Certification No. 07j 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 AFFIDAVIT4 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance 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 will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval ``F first obtaining approval. X /)9 t4�4" Date � d 3 X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date ' 3 b Submittal Amount Due �,� ,dam Receipt No. I LOS)-/ DPRTIVtEITAI:<;.; ;:II» �1PPRUVEt1 D ( ItwDN1�1Ipp^� N: al~ Building Dep nt `r ` e / U t��r Occ Grou Type Constr. v Planning Department Environmental Health Department Public Works Department I Fire Marshal j Valuation $ FE Building Permit Fee ( Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee Public Works Review Fee Mechanical & Base Fee OtherQ` Q Wood/Gas/Pellet Stove Fee Other 46 Violation Fee Pre-Paid at Submittal ( ) ><:< :z:<:< ,,. :.: .. >..� r:r;::f::y. `•° TOTAL FEES t PERMIT NO.: BI-CO MASON COUNTY BUILDING PERMIT APPLICATION 426 W.CedariP.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275.4467.Elma 360 82-5269 Seattle 20 4.6968 APPLICANT INF SMA CONTRACTOR INFORMATION Owner A110A view 1 V Contractor Name Mailin d ss Mailing Address ' City State Zip Code City State Zip Code Phone v other Ph.( - ) Ph: . ther Ph. Jfi Lien/Title Holder Contractor Reg.# ! ilC�tt►lN �{ A .Address Expiration '�•�' E m W�rT ER SYSTEM INFORMATWAct .,. gtlq�,�_Wiell Sewater Systemonnec Name of Sewer to m ,y/ Narrfg�CA w4s m ��""'1l��pll 1�1f System 'I PARCEL INFORMATION-12 digit Tax Parcel No. i A A A / / Fire District_ Legal Description 67 Site Address(Plea in I a re treet n mb r a d'c ty) fAL A D' dons tq site Mkt T�- Will timber be cut and sold in parcel preparation? (YeAffog k Is your property within 200' of the following: Body of Wp ► er(Name , Saltwater Lake River/Creek Pond Wetland -onall Stream Slopes or Bluffs ERMANENT RE DENCE❑ SEASONAL RESIDENCE❑ X New Add Alt Repair Other Use of Building s No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor Loft Basement Deck Other sq. ft. Att hed Detached Carport Attached Detached MOBILE HOME INFORMATION-Make"' .Model Model Year ��q,q Lengt<h�Width Serial No.� Its No. of BAtltr sue_ Type of Heat Arel i Purchase Price Do Replacemen nit .J�fef/No) Installer Name ertification No. {�,,,,,�' 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 H information provided is accurate and grants employees of Mason County access to the above described property and structures for review and Bey inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance 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 will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval first obtaining approval. X Date X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by . ' 4 Date " , Submittal Amount Due .t` Receipt No. �v l :.:. ... ............................ ......... Building De nt Occ Grou Type Constr. Planning Department J b.. Environmental Health Department Public Works Department 4 icy Marshal F. r. Valuation $ .::::............n..v...........................: .. ........................................................... ...v............................... Su:u�.slxr:::}::3.... .........................n................. .............:v..:::::........................................................... ....r ist[:i:??:iiiii�i:iii�>%{::`,:ii$jiiii:iii�i:{<�::::? {vi}ii::by:•Y{•i}i:?i}}iiY .....:OiY:•::::::::::::::: :•::.�:::::...:..::•.............................................................. Building Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee Public Works Review Fee r Mechanical & Base Fee OtherAll (� Wood/Gas/Pellet Stove Fee Other Violation Fee Pre-Paid at Submittal ( '7 k., TOTAL FEES .r PERMIT NO.: BL60 MASON COUNTY BUILDING PEROIT A,P,WCATION 426,W.CedarlP:O.goat 1sIG,Sheltan,WA 986s4 ei z Shelton 360 427.8670 Beltair 60 27ls"4401.Elate APPLICANT INF RMA CONTRACTOR INFORMATION Owner Contractor Name Maili d ss Mailin Address City State Zip Code City Sfate Zip Code 16 Phone res tither Ph.( ) Ph. trer Ph. Lien/Title Holder Contractor Reg:# Address Expiration LEC/W TER SYSTEM INFORIVIAT ct Ne Existing Septic Conne to of ,to y Nar Se "' LIP. ��`—Well_Water System System W PARCEL INFORMATION-12 digit Tax Parcel No. / / Fire District 1' gal DescriptionIMF Site Address(Plea inc de s re na treet n mb r a d`cl y D• Ions t slte WA I Will timber be cut and sold in parcel preparation? (Yes o Is your property within 200' of the follqp ing: Bodyy of W ref(Name 1E Saltwater Lake River/Creek Pond: t'{ Wetland Seasonal Runoff Stream Slopes or Bluffs ERMANENT RE ENCE(3 SEASONAL RESIDENCE OF J New Add` Alt: Repair`s Other Use of Building Desc ' e ork No. o rooms— No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor 3r oor Lofty Basement beck Other �sq. ft. a e Att hed .;Detached Carport Attached Detached MID E.HOME INFORMATION-Make` Model• Model Year _ Length Width Serial No, l's No. of B&&ddffis�_` Type of Heat Purchase Price 9, �.Q�0 Replacement Unit? o) Installer Name Certificatign No. NO,„„TILE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCECLW11'HIN 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: i OWNER AFFIDAVIT-1 certify that lam exempt from the requirements of the CONTRACTOR'S AFFIDAVIT4 certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance. 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 will be done in requirements regulating the work for which this permit is issued and all work r conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval. first obtaining approval. k X Date „7 X Date FOR,OF ICIAL USE BEYOND THIS POINT / Date ' ' Submittal Amount Due 3\tk . Receipt No. P r .Accepted by _ ..... ., Building De t © - •Occ Grou Type Constr. 441, 44 Planning Department Environmental Health Department Public Works Department Valuation $ Kf r +} k> -<•v. ...;.:+:.o.:'�. ;:{''�',£. f } c' t ;#,..,b:..a,v..},.. 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Building Permit Fee l 1) Site Inspection'. ` Plan Review Fee UFC Plan Review Fee, Plumbing & Base Fee Public Works Review Fee. Mechanical&Base Fee Other • � Wood/Gas/Pellet Stove Fee Other r� ,, Violation Fee Pre-Paid at Submltta ( ) TOTAL FEES, 5 : PERMIT NO.: B MASON COUNTIr BUILDING PERWT APP!LIC�.JION 1 426 W.Cedii r14.O.Box 186,Shalt a.WA,9856d, l Shelton 360 ,27-9870 Belfair 360 27544G7.Eima 380 -526,9 Seattle 20 644M APPLICANT INFQRMATION CONTRACTOR-INFORMATION` Owner Contractor Nam Mailing A Tess — Mailing Address Cit State Zip Code City Bta a Zip.Code Ile Phone Other Ph.( _ ) Ph.( . ? �'„r5 ' Other P .( LieriM le Holder Contractor Reg.# CRID% "A�2til- ` Address Expiration / / 1 i SEPTIGNyATNR SYSTEM INFORM A�1 N ec}e~t0 Ne Welling SeWater System V". to Name of 1 5ystern �✓ C.� Water System r� PARCEL INFORMATION digit Tax Parcel`No. ! / Fire District_ i ;legal Description � Site Address(Piee in ude str t n e, s rest um er n i y e tbons to sit PH 111 W► Will timber be cut.and sold in parcel preparation? (Ye , Y Is your property within 200' of the fo,loyvipg: Body of* opi(j m ) Jt Saltwater Lake River/Creek Pored;.- - .1t1#.e'tland Seasonal Runoff Stream Slopes or { Bluffs PERMANENT RE IDENCE❑ SEASONAL RESIDENCE ] E OE New Add Alt Repair Other ' Use of.Building Des 'b ork No. drooms No. of Bathrooms SQUARE FOOTAGE=1st Floor 2nd Floor_ 3 loo Loft Basement Deck Other sq. ft. rage Att shed Detached Carport Attached_____.,Detached. L ILE HOME INFORMATION-Make Model Model Year gth �� Width � , Serial No.' o lt�s n No.of at 'ms e of Hga M Purchase Price Replacement Unit l,No) aller Name Certificatiaallo. NOTICE: THIS PERMIT BECOMES NULL_8 VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT`COMMENCED WITHIN 190.DAYS OR IF, OONSTRUCTION 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 ytoperty and structures"for review and i,; . , inspection of this project: Acknowledgment of such is by signature below: ; OWNER AFFIDAVIT-I certify,that I am exemptfrom the requirements of the CONTRACTOR'S AFFIDAVIT-1-certify that I'am currently registered as a Contractor'Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that l am aware of the ordinance requirements for which this permit is issued and.that all work will be done in requirements regulating the work for which this permit is issued and all work. conformance therewith. No changes shall be made without first obtaining shalt be done in conformance therewith.. No changes shall,be made without ap{Sro first obtaining approval. �( Rate i V X Date FO OF DIAL USE BEYOND THIS POINT Accepted by Date ' 3 LSj Submittal Amount Due .dam Receipt No. s �r :...... Building D men VN k �` 5 Occ GroupT e Constr. I�'' Planning Department Environmental Health Department Public Works Department M � Ftre Marshal Valuation $ ....::...:... :.....:...n:... .:i.:?:.,.........:.........:.. ..r..r......n-......,...............,.. ...:.:.:}:..,L:::fin,•::S::Jp•::n:.�.....�....{.4..... u... } .. .... T:St':'{:.r.,{.:r,}....:.,.:.., 5 ...........::.. ......:v..\..r...n.....-.n,.......................✓..._................r.::••::•::::,...................... ....v.....•............:h .. ...x•::::•:::::..::.,.....,..............................:r:.i:!r:f... ......::•:::: :�.�:::.�::}.:.: --.:::::..;,.....✓....:.r:::r:,:-::r::::>::;}^r}:d:<".}}:{{<.-'JJJ.'•:xn:o-:•J:{,}}:{.;}:;;.};:.;r.;G} Building permit Fee - f) Site Inspection Plan Review Fee -UFC Plan Review Fee Plumbing & Base Fee Public Works,Review Fee. Mechanical&Base Fee Other *Afood/Gas/Pellet Stove Fee other - -Violation Fee Pre-Paid at Submittal ( ) TOTAL FEES Mason County Permit Assistance Center Planning IntakeC,leQklist [� Owners Name: �� G' +J` Date: � 1- Project: Reviewed By: Commercial Devel en Y O Comments: Planner: SAL GBM RAM PBC Site Ian: orth Arrow roperty Dimensions: X _ < 14 reets and Driveways Shown. Road name: Existing Structures shown with setbacks ell Location, Septic and Drain-field Shown with setbacks Identify all surface water (streams, ponds, shoreline, wetlands, etc.)n Topography(slopes) proposed Structure Setbacks (Direction/Setback): F: __/ _R: / S 1: / 4 S2: J)L/La— ❑ Utility and Drainage Easements: Yes No (if yes inter condition#5022) ❑ Other Easements Shoreline and Planning Info Setbacks: Shoreline: a K Slope: Sh�o eline Designation: Comprehensive Plan: Rural Zoning: V Not Applicable ❑ Agricultural ❑ RR 2.5 5 10 20 ❑ Urban ❑ In-holding ❑ RMF ❑ Rural ❑ LTCFL ❑ RC 1 2 3 ❑ Conservancy ❑ Rural ❑ RI ❑ Natural ❑ RAC ❑ RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT Urban Growth Area ❑ MPR ❑ Unknown ❑ Unknown Water Body (type of water if unnamed): � -�-- SEPA: Yes @ Unknown Flood Plain: YES NO Unknown ap# Aquifer Recharge: YES NO nkno'w)Map# Tags/Cases: TLC/SC Case: 6-Year Dev. Moratorium: YES Eagle Nest Tag: YES r! Other E U*, a Addressing: Check box if needed Reviewed by:Ott ❑ County Access Permit Needed(add condition#0010) __'' ❑ State Access Permit Needed(add condition#0020) g 289 E 6 y Standard Conditions to be added to all Building permits that planning reviews: ,�y t��J # 0046,# 4999, and# 5019 �`-� Re md:10/15/02 MASON COUNTY PROJECT SITE INFORMATION Case No; Name PARCEL NUMBER#' Date '� D SHOW THE FOLLOWING N SITE PLAN Show Directihn by indigationg N S, E;1N in relatioka to the site plan LiUof Dimensions TJ X7j7 -Fences xisting Structures Oveways -' ructure Setbacks 4 " orah � ater Lines vp 9 p Well tocation (including ad�acani) Drainage Plan Names of Streets', Easements i ?� Names of FronflhbJ tre s4 h Septic System k DRAW SITE PLA L W I de adjacent properties if on shoreline or within 100 feet of adjacent pro pert line. adjacent propeTty'llne- "'•""""""4'15 , E-adjacent property line 10 14� /IAANu FACi�cJ �rn� R�dyEdoc� der I%ne. • i 30 � . adjacent ro ert 1ine4 ' f-ad'acent roe line �f SAMPLE SITE PLAN "�`�" " adja�nt property lined I v aio' 30. tr ryVE ' E-adjacent property line y, I a �L _zE.4TY _� 1 ,gEA%Mai AL 'i HOMt - G0.6LN k y j PfaoPostD �,4- VAG►NT G+1ttA6e5 `• �� P✓9 oP �fl T IA&RZ �T�,►� So flu DNS—eo' Ply , FO� G� a J�M�OR�n c....eLL F1_ PROVED MASO BUILDING INSPioo' 0 r12 L , CHA S SUBJEC.f TO A, , DAIE TOPOGRAPHY PROFILE(Show a side view,of property. Show slopes, cuts and fills. if possible include height and the degree of slopes. See sample topography profile.) SAMPLE TOPOGRAPHY PROFILE ats+Av%e-& +.o Fr- to Slope to¢ des+a.,L Date Signature FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION Case No. Name Vim V61'G4V'—VPARCEL NUMBER Date SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plpn t Dimensions ]A71D FencesN/f( oF-xisting Structures vKriveways tructure Setbacks .64ereffnes- ater Lines V110pography Well Location (including adjacent) Drainage Plan Names of Streets Easements Names of Fronting Streets Septic System DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line. adjacent property lined __..__ 451 5 i <-adjacent property line i I I Ile I I I 17 I , I 14 I I 1 I � I fwcl�s 1 I I i I 1 / I 1 7p I I I I I I I adjacent property line-> I Z 1 E-adjacent property line SAMPLE SITE PLAN LOT I L saCdEj2aa�rsc t property line ; 32.0' Fadjac ent pro perty line� 0-f— so' rarsVe u A" a L _�rw- v. -) MOM t" ,GridlN 1 Hous4 I j Priap smptrc 1 1 , 1 VACAkiT I fi G,ARAc.6 I / PaoPmea � T A&R=LLLTUJ%Ar_ 1 14--40 90' 1 / 1 � I 80, � 1 /00 I I I I L- -eLL I I 1 00. -1 c adjacent property line4 ; E-adjacent ro ert'line TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the degree of slopes. See sample topography profile.) SAMPLE TOPOGRAPHY PROFILE dlshanta, to ructu.re- di%-t'ar+Cr- f. S►opm �-o¢ 06 distant¢ 5 +o lot i6 I i � 03 Signature Date l�J �lool oo 5 P4J ur/4 2g � n i9 FILE n COPY APPROVED MASON BUILDING INSPECTOR CHANGES SUBJECT TO AP ROVAL DATE 1> Documents attached to approved plans: Site Plan „ .. Plan review cheeki' •.. -Pages Engineering: Y . Laterai Vertical Num r of pages k- L l4ow,