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Dy Dato By FIRE DEPARTMENT Foundation Walls Floors Date C Date By Data By DECKS FRAMING Walls Date By Date By Data By PROPANE TANKS PLUMBING vault Date By Date By OTHER Groundwork Attic Date By Date By Type: Date By D.W.v DRYWALL Type. a'e ByInt Brace Wall Date By W 7 Date By FINAL INSPECT10N 0 v Water Line Fire SeporationCn N Date By Date By Date By o m -I Pass or Request Inspect. b Type of Insp. Fail Date Date Done By Comments �. y✓o�'K ry s vTfo o174V -CC- SIC Tl��i l.*ior�40 f�,y ©•+� sii Goy Ago o P W Rig �s� G.sr,E �^- Tv 7-W6 C Jr cn 47 0 8 SS 2-0 - 2-p- /c� _ a . . _ Cn U O 4 I 4 i O ti. l KmA t-OkS 37�? -a � p Plot Map Drawn To Meet k�• ���-' HiLine Homes Specifications. is Any Revisions To Be Made a 1 By The Homeowner. a P"" L A H HI I 1"4 G PLANNING. ALL SETBACKS ARE MEASURED je FROM THE FURTHEST PROJECTI ING MASON COUN D PLANNING ° SITE PLAN REQU D BE ON SITE A GES S JECT TO ROV I By Date �©� r APPROVED ,�c LE MASON COUNTY DCD PLANNE'NG SITE PLAN REQUIRED TO BE ON SITE CHANGES SUBJECT TO APPROVAL j By Date MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health Personal Health PO BOX 1666 SHELTON, WA 9858 LOCAL(360)427-967 (360)275-446 Application for Determination of Adequacy BEL FAIR AX(360)427 779 Instructions 1. Corriplete Par# No determtraation car- be lade urifill Psirf:l I$fglly oofrile _ 2. Complete only the portion of 0 ft 2 applying to the iy a of +titer sy t r>t Vol 3. ukmafi'eorrt leted`e. IiCAP_in,:HtitFl attchtt� rj'# ,to ttae filth d " rtmerltfor review. - PART 1: Applic caant/Parcel Identification Name of Applicant_--rot.). K0,,04P,S Date Mailing Address 37 Z-7 Wes k" Lp- A) Telephone 3�y� 8 -9 tog OtlAtm fl-A, w aZ Assessor's Parcel Number 3 Z 13 3/6 9©O 1 I Type of Water System Check One): Reason for Application Check One): ❑ Public/Community Water System(2 or more Building permit connections)" ❑ Land use application, if so.. Individual water source(one connection), ❑ Division of land: if so.. Well #of Parcels? SPL ❑ Spring/surface water ❑ Boundary line adjustment ❑ Other(explain) . ❑ Other(explain) ** If you have more than one residence ❑ Replacement(please indicate name of water system connected to this well,check the Public box, below if applicable—no signature required) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water System Name of Water System Water Facility Inventory (WFI) Number: (write "none"for two party) ❑ I am the manager of this water system. The water system has been approved for services. There are presently connection(s)in use. This will be the connection. ❑ I am the manager of this system. This connection will be to upgrade or change the use of an existing connection on this system(ie: recreational to full time). Please indicate on the following line the nature of this change: This water system is able and willing to provide water to this(these)connection(s)without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date H.•IWEWWEBPAGEIWEB SITEI WATERAD4.DOC Update:April 2006 Individual Water Well Water well report(attach to application) Depth ft. p 44 AC 1, 1 nG' —Go ,, A"c►a ,(A ❑ Well capacity test(attach to application) gpm gpd e well driller often performs we capacity tests at the time the well is cons ruc e . Resu s from 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 stabilizagon of draw- down and recovery data must be performed by a licensed contractor. ❑ Satisfactory bacteriological test(attach to application) Individual S rin /Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection ❑ 1 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. PART 3: I:eallih 0e0sirtment;Eva1uatIdi11 (St6 Vs4.,0n1y) 11 SATISFACTORY DETERMINATION:.Applicants water supply appears adequate to meet the needs of its ihtended use. This determination does not address adequacy o bution system, guaranteer an adequate supply of water indefinitely.into the future, or guarantee compliance with all applicable�UIIDOE"ter.resourde.iegatations: UNSATISFAGTORY DETERIVIINATI�N:Applicant's water"supplyy does�not appear a�d— a't�to rni�et the.needs of-its ntehded use for.the folldvumg reason (s): REVIEWER'S SIGNATURE DATE H.I WELLI WEBPAGEIWEB SITEIWATERAD4.DOC Update:April 2006 A MUST BE COMPLETED IN INK CASE PRESS HARD MASON COUNTY PERMIT NO.64 -d l 1 BUILDING PERMIT APPLICATION -5 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 Shelton (360) 427-9670 - Belfair(360) 275-4467 - Elma (360) 482-5269 1On the web www.co.mason.wa.us APPLIC NT INFORMATION CONTRACTOR INFORMATION owner ✓` e Company Name mailingAddress ( Mailing Address City StatelLA Zip Code City State Zip Code Phone 26b WZ7 03/7 Other Ph. q3 Z S14`� Phone Other Ph. i:ien,T:.,e , _ Contractor Reg.# Exp. Fine"address` E Mail Address Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Con t to Water System Name of Water System Well � Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. Fire District Legal Description Site Address(Please incl de street e, street number and city) Di ctions tb site L Wi11 timber pelcut and sold in parcel preparation?Yes No Is property 6 in 200' of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluff 15% Is this permit submittal the esult of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repai O her PRIMAIPA— RY R SIDENCE ❑ SEASONALaizzi ❑ Use of Building Describe Work In No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck—_Other Sq. ft. Garage Attached Detached Carport Attached Detached MANU CTURED ME INFORMAT - Make Model Year Lengt Widt Serial No. N . ofLBdooms o. of Bathroype f He t Purch a Price $ R men nit? Yes o st ler Na Ce n 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 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. This permit/application becomes null & void if work or authorized construction is not commenc ..hin 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS OF RO ESS INSP CTION.IN PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: Owner/Owners Representative/Contractor (indicate which one) Em FOR OFFICIAL USE BEYOND THIS POINT Accepted b Date — DEPARTMENTAL REVIEW APPROVED DENIED NOTES Buildina Department 426 W. Planning Department I Environmental Health Department Fire Marshal FEES � Site Inspection Buildina Permit Fee Plan Review Fee EH Review Fee Plumbing & Base Fee Planning Review Fee Mechanical & Base fee Other Wood /Gas/ Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES MASON COUNTY PERMIT NO.6r" -6/(0 BUILDING PERMIT APPLICATION ? - z 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 I = 'Shelton'(360) 427-9670 • Belfair (360) 275-4467 - Elma (360) 482-5269 Ci. .... On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION owner __., tr Company Name Maili q Address .. `? ✓` k c l± t. Mailing Address City L' StateVJ A Zip Code 7 City State Zip Code Phone l 4 17 to✓0 Other Ph. `_ -' Phone Other Ph. Contractor Reg.# Exp. E Mail Address Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Conq4ct to Water System Name of Water System Well Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. a " '`` Fire District Legal Description Site Address (Please include street e, street number and city) ,ti 6+ Di pctions td site �. `^ 4 - c > Will timber din ut and sold in parcel preparation?Yes No Is property 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff � Stream Slopes or Bluffs Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New_V Add Alt Repair Other PRIM .RY RF-SIDENCE ❑ SEASONAL ❑ Use of Building Describe Work=e No. of Bedrooms, No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor - Basement Deck Covered Deck SZ4) Other Sq. ft. Garage Attached Detached Carport Attached Detached MArfHe CTURED ME INFORMAT N - Make Model —Year Widt Serial No. N . of Bedrooms o. of�Br ,'Typ t Purch e Price$ R 1acemen nit? Yes VoI' sta Ce n 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 am entitled to receive this permit and to do the work as proposed in the application. I declare that 1 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. This permit/application becomes null & void if work or authorized construction is not commenc thin 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF ROGRESS INSPECTION.��-eF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPL(CATION. X_� �.., / ,, Date: Owner/'Owners Representative'/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date DEPARTMENTAL REVIEW APPROVED DENIED I NOTES Building Department f - C;Z Planning Department 9 1$ 07 Environmental Health Department P y q Fire Marshal FEES ! Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview Fee Mechanical & Base fee Other Wood /Gas/ Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES MASON COUNTY PERMIT NOA _L 1MQ I �7 BUILDING PERMIT APPLICATION - t 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 ! - —Sheltcm (360) 427-9670 - Belfair(360) 275-4467 - Elma (360) 482-5269 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION 6wner Company Name Mailin Address f�a• L� c Mailing Address City o _StateSL��Zip Code S`ts City State Zip Code Phone ':?&h Y'Z7 03f 7 Other Ph. 1 : Z S`I4 J Phone Other Ph. Contractor Reg. # Exp. E Mail Address f Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Con t to Water System Name of Water System Wel[4i&±L Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. 10- q6n I I Fire District Legal Description Site Address (Please include street e, street number and city) Di ctions t6 site L ' Wil timber e cut and sold in parcel preparation?Yes(No Is property in 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Is this permit submittal the,result o a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repairs„ Otheer� PRwig-, MARY RFESIDENCE ❑ SEASONAL ❑ Use of Buildin Describe Work � 4 -A wig i No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor 2nd Floor 3rd Floor Basement Deck Covered Deck—Other Sq. ft. GaWge Attached Detached Carport Attached Detached MAnfHe TURED ME INFORMAT N - Make Model Year LenWidt Serial No. N . of Bedrooms o.�ofBath�ro �_'yp Purch e Price $ R lacemen nit? Yes I st Ce n 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 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 i described property and structure for review and inspection. This permit/application becomes null &void if work or authorized construction is not commenc hin 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF ROG ESS INSP CTION.IN ,HIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. I X Date: Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date T DEPARTMENTAL REVIEW APPR,9XED DENIED NOTES Building Department 0" 426 We C %. Planning Department Environmental Health Department l Fire Marshal FEES Buildin Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee PlanningReview Fee Mechanical & Base fee Other Wood /Gas/ Pellet Stove Fee State Fee SO Violation Fee NO Pre-Paid at Submittal Valuation $ �v �� TOTAL FEES ��rnr r FORM MUST BE COMPLETED IN INK PLEASE PRESS HARE) MASON COUNTY PERMIT NOA —dm. 6�_ BUILDING PERMIT APPLICATION -:5 I 426 W. Cedar- P.O. Box 186, Shelton, WA 98584 ( 3 Shelton (360)427-9670 - Belfair(360) 275-4467 - Elma (360) 482-5269 _ On the web www.co.mason.wa.us APPLIC NT INFORMATION CONTRACTOR INFORMATION 6wne Company Name Cl�ailin AddressL$�, G t- Mailing Address ity :_;Statel6AZip Code_ ` City State Zip Code Phone -?(w5 Y 2 63/7 Other Ph. y-3 Z 514 5 Phone Other Ph. _._ Contractor Reg. # Exp. ;=me"�,��,���_c_._ E Mail Address n nnR Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Con t to Water;:yste!m Name of Water System WellrII&IL Sevier System Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel No. Fire District Legal Description_._.. � Site Address (Please in cl de street0fte, street number and city) Di ctions tb site Will timber a cut and sold in parcel preparation?Yes No Is property in 200'cf Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs 5% Is this permit submittal the result o a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New_y Add Alt Repair_Oher PRIMARY R SIDENCE ❑ SEASONAL Use of Building_____ Describe Work No. of Bedrooms_— No. of Bathrooms Square Footage- 1st Floor 2nd Floor 3rd Floor. _Basement Deck Covered Deck Other Sq. ft. Garage _. A•:tached Detached Carport Attached Detached MAN URI:.D F ME INFORMAT N - Make Model Year LenWi(it Serial No. N\�ofBedrooms �Yeso of Bathroor yp Purch a Price $ lacemen no I st Ce ' ' n 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 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 a 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 appli(ation, 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. This permit/application becomes null& void if work or authorized construction is not commen hin 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS OFXPROGIRESS INSPECTION.IN t=-fiHIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Dates Owner/Owners Representative/Contractor (indicate which one) a FOR OFFICIAL USE BEYOND THIS POINT Accepted b Date DEPARTMENTAL_ REVIEW APPROVED DENIED NOTES Building Department Planning Department 426 W9 Environmental Heal_h Department Fire Marshal r� W FEES Building Permit Fees Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee Planning Review Fee Mechanical & Base fee Other Wood/Gas/ Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal