HomeMy WebLinkAboutBLD2005-01920 Final SFR - BLD Permit / Conditions - 11/30/2005 W
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PLOT PLAN
Name MARUON RAINS
Mailing Address 28U M ME►.Lt50. LANE SMEL'rOM . WA , 98524
Home #j"60 !J21- 5:1611 Work # Cell #
Property Location_ I HaD M MASDIJ LK RD . SNE.?o No WA, q 2 84
Legal Address TS 21 N R--Ab'Sec 34 Tax Lot #_3213431900 41
MkSW County, State of WA .
THE INFORMATION ON THIS PLOT PLAN HAS BEEN PROVIDED AND REVIEWED BY THE PROPERTY
OWNER WHO BY SIGNING BELOW:1)ACKNOWLEDGES AND ACCEPTS FULL RESPONSIBILITY
FOR ITS ACCURACY AND COMPLETENESS.2)IS RESP014SIBLE TO ENSURE THAT THE
IMPROVEMENTS TO THE SITE TAKE PLACE IN CONFORMANCE WITH THIS PLAN:3)WILL
ESTABLISH ALL THE CORNER IRONS.LOT LINES AND CODE-REQUIRED SETBACKS REQUIRED OF
SCALE: V' = THIS PROPERTY.ANY CHANGE(S)TO THIS PLAN MUST BE PRE-APPROVED BY THE
GOVERNMENTAL AGENCIES WITH JURISDICTION.THE MORTGAGE LENDER AND THE
CONTRACTOR AND DOCUMENTED.
OWNER SIGNATURE DATE
l� t
OWNER SIGNATURE DATE
01
J r o
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
En*onmental Health - ---
Personal Health
PO BOX 1666 SHELTON, WA 98584
LOCAL(360)427-96'?0
Application for Determination of Adequacy BELFFAX(360)427-7798
Instructions
1, Complete Part I. lip, ua be mays. ti Past 1 is fully.cnmeted.
Complete only t1e:pe pf3t �npping tcI the hype of water systerri utilised.
3- t#bmit co lets :. ct ts; the heat 4 . qx t.for teview;
PART 1: Applicant/Parcel Identification
Name of Applicant —may t 1v�"1 S ate 1
� n ,, ,�D,
Mailing Address -��/ `�t/,�+� ,1 e ephone VI J
Assessor's Parcel Number '
Type of Water System (Check One): Reason for Application (Check One):
❑ Public/community water system(2 or Bui ding permit
more connections) . New
❑ Private Two-Party ❑ Replace Existing Structure
Individual well(one connection) ❑ Land use application,if so...
Well ❑ Division of land-
0 Spring/surface water #of parcels?
❑. Other(explain) SPH2
❑ Boundary line adjustment
❑ Other(explain)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water S stem/Private Two-party
Name of Water System
Water Facility Inventory(WFI)Number(enter"none"for Two-Party):
O The water purveyor has filed a letter granting blanket hookups to this water system
CI I am the manager of this water system The water system has been approved for services. There are
presently connections in use. This will be the connection.-This- system is able and
willing to prove a water to this(these)connections without excee g the limits of the water system or any limits
set by state and local regulation.
Signature of Water System Manager Date
H.I WELL I WATERAD3.WADOC Update:March 22,1999
Individual Water Well
Water well report(attach to application) Depth ft.
Well capacity test(attach to application) gpm gpd
e well driller often performs well capacity tests at-t e time the well is constructed. Test re-sultsfrom
these tests are noted on the water well report. Results-from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity
test, a well capacity test, which provides stabilization of drawdown and recovery data, must be
performed by a licensed contractor.
Satisfactory bacteriological test(attach to application)
Individual Spring/Surface Water
o WDOE WR permit(attach to application)
❑ Method of Disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons'per day and/or
provides water at a rate of 2 gallons per minute based on the following observations
Author of Statement Date
Relationship to applicant
In addition to providing the above statement,the applicant will need to arrange an on-site
inspection by the health department prior to determination of adequacy.
Departmental use only. Do not write below this line.
VOW
T Y
:appearstwo
Owv
xri .
4 g9
s "et Oft Qtion daes c1'of thet grantee
; supply of �., e future. Izczrcce wr {
'DOE w
.: rs.
C ACTO f t Y does jift
a * F
Meet the �..
- Wed use (s); .�-�. ,
-t- t
.x.
H.IWELLIWATERAD3.WRDOC Update:March 22,1999
MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
WSEC/VIAQ Compliance Application
Owner: S Telephone:4?-7 Parcel#:
Type of project ( ew Residence ( )Addition ( ) Remodel
Total Sq. Ft. 1 S Floor: ' I 2" floor: Heated Basement:
of heated area::
Heating System Type: lectric wall heater O Electric Central Furnace O LPG Furnace
O Heat Pump with electric furnace O Heat pump with gas f nace O B filer specify fu I t pe:
O Other: Specify-
Glazing Compliance Prescriptive Option see reverse side circle one: I II I 10
Percentage: pliance
Method O Component Performance , Chapter 5— Calculation worksheets required
Check one::
O —Systems analysis, Chapter 4
Whole House Ventilation system O Whole House Ventilation using a Heat
Ventilation using exhaust fans&window or wall fresh air g
Recovery Ventilation System (VIAQ 303.4.4)
System vents (VIAQ 303.4.1)
Check one
O Whole House Ventilation Integrated O Whole House Ventilation using an inline
with a Forced Air System (VIAQ 303.4.2) supply fan. VIAQ 303.4.3)
Window & Door Schedule (If needed, attach an additional sheet)
Total
Manufacturer Room/location U-Factor Size Quantity Square Tot of Feet
Windows:
Windows: Total Sq. ft.
Doors:
Doors: Total Sq. Ft
Total window and door area
Total window & door area /(divided by)total sq. ft of heated area = %of glazing
FORM � � k0N MUST BE �OMPLETED IN INK IVIA COUNTY PERMIT NO.
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W.Cedar- P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670- Belfair (360) 275-4467- Elma (360) 482-5269
On the web www.co-mason.wa.us
APPLIC INFORMATI CONTRACTOR I MATT
Owner �J Company Name
Maili ddress Mailin Addres Id
City tate TZipCode City State Zip Code
PhoneL
�flk'D Other Ph. Phone - Oth Ph.
Lien/Title Holder Contractor Reg. xp,
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic existing Septic
Connect t ater System Name of Water System
Well Water System Name of Water System
PARCEL INFOR IOI!TgirnplNo. Fire District
Legal Description
Site Address (PleVqcWde s rpet rjame, street number and city L
D'r ctions to IT
7t"
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of Saltwa ake River/Creek Pond
Wetland Seasonal RAn tream Slopes or Bluffs J 15%
Is this permit submittal the esult of a Stop Work Notice,Correction Notice or other enforcement actio e
TYPE OF JOB - e Add Alt Repair Other P Y RESIDENCE SEASONAL ❑
Use of Building Describe ork No.of Bedrooms No.of Bathrooms-Square Footage- 1st Floor 2nd Floor
3rd Flo r Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - ak Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? Yes/No
Installer Name Certification No.
OVVNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or t of
Y op permit revocation.
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further 4oi this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the If'permission is
required from any easement holder or any other party in interest regarding this application or the work proposed i e applicati I ned
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,regnl> �rmation
Pr7q�wnger/
ovided is accurate and A�rants employees of Mason ORK IS BY MEANS OF A P OGRES access to theSINSPECTIO�{d pro�p1erty and structure for r ew an ins iQn.Y
X Date: i, MASON t�1 t
Owners Representative Lcatractor - dicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED- NOTES
Building Department
Planning Department �_ }
Environmental Health Departmen -
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing &Base Fee Planninq Review Fee
Mechanical& Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation$ TOTAL FEES P
;-
oil-
NI iON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma.(360) 482-5269
On the web www.co.mason.wa.us
APPLIC INFORMATIf CONTRACTOR 1 MATIO
Owner ` 1�;a
Company Name Y �l: }
MailiW ddress '' z ; Mailing Address-.. '` < -
City `l State ",: Zip Code City " -N )V State Zip"Code
Phone l Other Ph. Phone Othe Ph.
Lien/Title Holder Contractor Reg. xp. -
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/ AT
SYSTEM INFORMATION - Connect to New Septic Fxisting Septic
Connect t ater System Name of Water System
Well Water System Name of Water System
PARCEL INFORM#71ON - 11�,Digit,jar(�pl No. ' 1711, Fire District
Legal Description �• ?
Site Address (Ple e.' c ude street name, street number and city �( ` I
Dlrections to s't " _� 1 -. , { ti
{ (..
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of Saltwat Lake River/Creek Pond
Wetland Seasonal R n tream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement actioFYe
TYPE OF JOB - lew Add Alt Repair_ Other i P Y RESIDENCE SEASONAL ❑
Use of Building J / rt, Describey�ork
No.of Bedrooms�_No.of Bathrooms ;,1 Square Footage- 1 st Floor 2nd Floor
3rd Flo Basement Deck Covered Deck Other Sq.ft.
Garage_r Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - ak Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
Type of Heat_ Purchase Price$ ---- Replacement Unit? Yes/No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit n. ment of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further decla�t I entitle ive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessa i i ion is
required from any easement holder or any other party in interest regarding this application or the work proposed in the appl�,Yhave obtain
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents th t o
prove is accurate and grants employees of Mason County access to the above described property and structure for � ite s ion.
QF �JN NUATIC�N�r F WORK IS BY MEANS OF A PROGRESS INSPECTIO Iv►
X ' Date:
wner/Owners Representative C6htractor dicate which one
FOR OFFICIAL USE BEYOND T S POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Departmen
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planninq Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation$ TOTAL FEES
...... ...... .
FORM MUST BE COMPLETED IN INK ' MASON COUNTY PERMIT NO.
PLEASE PRESS HARD
BUILDING PERMIT APPLICATION
426 W.Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670• Belfair(360) 275-4467• Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLIC INFORMATI CONTRACTOR I MATI
Owner CJ Company Name
Maili ddress Mailin Addres
City tate Zip Code City State Zip Code
Phone - Other Ph. Phone - Oth Ph.
Lien/Title Holder Contractor Reg. xp. -'
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect t ater System Name of Water System
Well Water System Name of Water System
PARCEL INFOR 10 - 1;2 Digi ar I No. Fire District
Legal Description V ,
Site Address (Ple inc de s r me, street number and city twu
Directions to sit 1
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of SaltwAn
ake River/Creek________Pond
Wetland Seasonal R tream Slopes or Bluffs > 15%
Is this permit submittal the yesult of a Stop Work Notice,Correction Notice or other enforcement actio e
TYPE OF JOB . e Add Alt Repair Other P Y RESIDENCE M SEASONAL �]Use of Building Describe ork -
No.of Bedroom No.of Bathrooms!Square Footage- 1 st Floo 2nd Floor.
3rd Floor_ Basement Deck Covered Deck Other_Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - ak Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? Yes/No
Installer Name Certification No.
C M M/BULDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Ac¢ of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all thVe . permission '
required from any easement holder or any other party in interest regarding this application or the work proposedpermission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf, PPI� I brma
on
provided is accurate and grants employees of Mason County access to the above described property and structure for
�c�ti�o�
P TI F WORK IS BY MEANS OF A PROGRESS INSPECTION i ti MASON COand S U N t Y
X ' l Date:
ner/Owners Re resentative C tractor dicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED' NOTES
Building Department
Planning Department
Environmental Health Departmen ) -
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing &Base Fee Plannina Review Fee
Mechanical& Base fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation$ TOTAL FEES
1,4 n
MA ON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLIClu'vin�q
FORMATIO CONTRACOR IN MATTOwner � Company Name J
j Mailir)g ddress if Ig Mailing Addres
Citv In Phone _ 'State Zip Code City-0State Zip Code
Other Ph. Phone - Other Ph.
Lien/Title Holder Contractor Reg.
xp.
Email address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Fxisting Septic
Connec/tNater System Name of Water System
Well Water System Name of Water System
PARCEL INFORM IO - 12 pt a igir I No.
Legal Description LI Fire District
Site AddressAM
c ude strrjame street number and city)Drections to G
Will timber be cut and sold in parcel preparation?Yes/No
Is property within 200'of Saltwa ake River/Creek Pond
Wetland Seasonal R n tream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement actio e
TYPE OF JOB - No Add Alt Repair Other P Y RESIDENCE SEASONAL ❑
Use of Building Describe ork !
No.of Bedrooms No.of Bathrooms.__2_Square Footage- 1 st Floor- 2nd Floor
3rd Flo r Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - ak Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
i Type of Heat Purchase Price$ ---- Replacement Unit? Yes/No
Installer Name Certification No.
OWNER/BUILDER Acknowledges 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,owners legal representative,or the contractor.I further declare that I arp receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the nec "a e�ssery p n,I h e obi in
is
required from any easement holder or any other party in interest regarding this application or the work proposeetira'ff�"ie�Gcatlon,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners If;�fepresent, tt information
Iprovided is accurate and grants employees of Mason County access to the above described property and structure foVTge y'�d pection.
PR= NT N ATI F WORK IS BY MEANS OF A PROGRESS INSPECTIO .tt ,,yy N GOVN-�`(
X Date• 1r.O
Owner/Owners Representative C tractor ' dicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW AFPROVED DENIED NOTES
Building Department r
Planning Department
Environmental Health Department
Public Works Department -r Zoo3-���
Fire Marshal
FEES
Building Permit Fee a _ Site Inspection
Plan Review Fee o� y, •5 EH Review Fee
Plumbing & Base Fee 4- Planning Review Fee
Mechanical & Base fee 5 .Cps' Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee r9C_2P i Pre-Paid at Submittal (. J
Valuation$ ` 79• O TOTAL FEES I
MASON COUNTY PERMIT NO. �2 (2�•fir?
PLUM BING/MECHANICAL PERMIT APPLICATION
426 W.Cedar•P.O.Box 186, Shelton,WA 98584
Shelton (360) 427-9670•Belfair(360)275-4467• Elma(360) 482-5269
On the weD www.co.mason.wa.us
OwnerAPPLIC NT INFORMATIr N CONTRACTOR INFO ATIO
Company Name 1 _
Mailing AAAres Mailing Address 1
City �a ,►_State 'O Zipp Code `f City ` '� ' ' ZipCode
tate
Phone Phone Other Ph.
Lien/Title Holder Contractor Reg. iUExp, . `J I
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
.60iSEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System
Name of Sewer S stem
PARCEL INFORM TIO . 12 Di i Parcel No. 1- -' Fire District
Legal Description
Site Address(Ple a in lude greet name. street number and city)
Direct', s to site 4 f " , ( ' 4 {
Is property within 200'of altwater J Lake River/Creek Pond
Wetland-Seasonal Runoff Stream Slopes or Bluffs ? 15%
TYPE OF JOB - New_&Zkdd Alt Repair Other Use of Building
Location of Fixtures/Units- 1 st Flood Floor Basement Gara a Closet
PLUMBINGFIXTURES(Show Number of each) MECHANICAL UNITS
Type of Fixture No. f Fixtures Fees Fuel Type:Electric�/y LPC� Natural Gas Heat Pump_,_,_
Toilets Type of Unit No.of Units - F s
Bathroom Sink -�' Furnace "-Bath
Tubs_ Heatpumps
Showers Spot Vent Fan
Water Heater I Propane TankT
Clothes Washer 1 Gas Outlets
Kithen Sinks , Wood/Gas/Pellet Stoves
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
O MVER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.AclawMedgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.if permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review,and inspection.
P .. QONT1j=OF WORK IS BY MEANS OF A PROGRESS INSPECTION L�
X Dater
Owner/Owners Representative ,Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by:_Planning Pd Ck# Date Bld Pd_Receipt No.,_________,
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
cc Grour)-Tvoe Constr.
Planning Department
Environmental Health Department
FEES
Plumbing&Base Fee Site Inspection
Mechanical&Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Vio
lation Fee TOTAL FEES
i
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PRESS HARD
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar•P.O. Box 186, Shelton,WA 98584
Shelton (360) 427-9670•Belfair(360)275-4467•Elma(360)482-5269
n the web www.co-mason.wa.us
APPLIC T INFORM I ,N CONTRACTOR IN 10
Owner Company Name
Mailin Ad r s Mail'in Addres
City -State 16MZip Code City tate Zip Code
Phone — Other Ph. Phone — er Ph.
Lien/Title Holder Contractor Reg. Exp. 1 -0
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFOR TIO - 12 D'riP Fire District
Legal Description .
Site Address (Pie in Jude free a street number and cl )
irec ' s to site 5t
Is property within 200'of altwater Lake River/Creek Pond
Wetland Seasonal unoff Stream Slopes or Bluffs 1 15%
TYPE OF JOB - New Add Alt��Repair Other Use of Building
Location of Fixtures/Units- 1st Floor_ 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UN
Type of Fixture Txtures Fees Fuel Type:Electric_ LPG_ Natural Gas`_ Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer Gas Outlets
Kithen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDER Acknowledges 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,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the worts as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROG
520hTIP"OF WORKS r&BY MEANS OF A PROGRESS INSPECT
X Date:
Owner/Owners Representative Ocontractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Grou T e Constr.-
Planning Constr.—
Planning Department }
Environmental Health Department
FEES
1PIumbinq& Base Fee Site Inspection
Mechanical&Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES
MASON COUNTY PERMIT NO.
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar•P.O.Box 186, Shelton,WA 98584
Shelton (360)427-�67 0B -4467•Elma(360)482-5269nhe web www.co.mason.wa.us
APPLIC NT INFORMA 1 N CONTRACTOR IN ATIO
Owne Company Name P '
Mailing Ad r s MailingAddress
City tate 1j��Zip Code City tate Zip Code
Phone Other Ph. Phone
t er Ph.
Lien/Title Holder Contractor Reg.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septic
tic
Name of Sewer System
Connect to Sewer System
PARCEL INFORffIO,�- 12 Di Parcel No. Fire District
Legal Description
Site Address Ple
I ( Er in Aude ��e$na , street number and city) 1 % -<, In
Direct s to site �# l (j
Is property within 200'of altwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
TYPE OF JOB - New Add Alt�—Repair Other Use of Building
I
Location of Fixtures/Units- 1st Floor_& 2nd Floor Basement Garage
Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNVS
Type of Fixture No.Df Fixtures Fees Fuel Type:Electri�_ LPGj— Natural Gas__ Heat Pump_
Toilets Type of Unit No. of Units Fees
Bathroom Sink Furnace
Bath Tubs c1 Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer �_ Gas Outlets
Kithen Sinks �_ Wood/Gas/PelletStove
Dishwasher I Kitchen Exhaust Hood
f Hosebibs _ Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDER Acknowledges 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,owners legal representative,or the contractor..I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PR O I TI OF WORK S BY MEANS OF A PROGRESS INSPECTI N I
X Date: �!
Owner/Owners Representative OContractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group-Type Constr.-j
Plannin Department
Environmental Health Department
FEES
,Plumbing & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES