HomeMy WebLinkAboutBLD2006-00023 Final SFR and Water Adequacy - BLD Permit / Conditions - 1/6/2006 W
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FORM MUST BE COMPLETED IN INK PERMIT NO: BLD
PLEASE PRESS HARD MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360r427-9670 Belfair 360 275-446T Elma 360 482-5269 Seattle 206 464.6968
APPLICANT INFORMATION CONTRACTOR INFQRjNAT10
/�/e
Owner m,,�� Contractor Name
Mailing Address 3 Mailinn Address S
Cit)l 'vgrc 4l,p_ State Li►4 ZiA Code City t=- State W Zip Code g -�
PhoneGZ&c: )..39L-not Z Other Ph.( LO i�•S68/ Ph. ether Ph.(
Lien/Title Holder Contractor Reg. # lluNN*901 IVY
Address _ Expiration /) / 0-7 /0_
E
TIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
em Name of Sewer Systems Sr a 4 2 ens-Pete) Well Water System,�_Name of
er System4;S_W
PARCEL INFORMATION-12 digit Tax Parcel No. _► Z i n 7 / _/ 0 3 �/ Fire Distri
Legal Description
Site Address(Please include street name, str et num er Ind city) so
Directions to sit Gr,,, J.,R o
-Amid -eiv
Will-limber be cut and sold in parcel preparation? (Yes/No)_AL(3
Is your propety within 200'of the following: Body of Water(Name)�� Saltwater jam_
Lake_�ilj I�iverlCreek�� Pond�i Wetland A/v Seasonal Runoff_Stream� Slopes or
Bluffs_
PERMANENT RESIDENCE_X SEASONAL RESIDENCE❑
TYPE OF JOB New_ Add Alt Repair Other Use of Building
Describe Work JJ!_f"I _Sr;,` - Id—![ .c.A G I., ..
No. of Bedroottts__.3LNo. of Bathrooms, S SQUARE FOOTAGE-1st Floor,-231f _2nd Floor
3rd Fluor — Lott - Basement -_ Deck_J(.v _Other
Garaqe Attached ✓ Detached Carport Attached Detached sq. ft.
MOBILE HOME INFORMATION-Make Model
Length Width Serial No.
Type of Heat o. o edrooms No. of Bathrooms
Insta'
rlce Replacement Unit ?(Yes/No)
Certification 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
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 b sic n ature bet y J ow:
OWNER AFFIDAVIT-I certify that I am exempt from 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 I am aware of the ordinance
requirements for which this permit is issued and that all vxbrk 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 lirst obtaining shall W donq in confor nce th approval. first o
ey No changes shall be trade without
btaini r
rX
ate
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by � Date ) DOLPSubmiltal Amount Due
Receipt No.
DEPARTMENTAL REVIEW APPROVED :'DENIED: CONDITION CODES::.. ...
Building Department
Occ Group Type Constr.
Planning Department ;
Environmental Health Department �
Public Works Department 1
i I
Fire Marshal
l
Valuation
FEES
Building Permit Fee ( -� q � .3s� � Site Inspection
Plan Review Fee i EH Review Fee
l
Plumbing&Base Fee ! ( 2 3 Planning Review Fee
Mechanical&Base Fee g S . �/ Cther
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee C
/vb F Pre-Paid at Submittal
s_
ar
F !
z r: � 3,a�,' TOTAL FEES
MASON COUNTY PERMIT NO.
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
On the web www.co.mason.wa.us
APPLICANT INFOfi1V1ATW.N CONTRACTOR INFORMATION
Owner r-b C0 /JJ W.
Company Name '
Mailing Addre s l#1 47 A/t.J A&i 4n AC A5 2ol Mailing Address Z
City vex State Lyd-Zip Code 9 F 3 8.3 City 1 �» State��Zip Code�ls'S//
Phone yy $/ S'G G/ Other Ph 00 2 Phone Ua qrz v? So Other Ph
Lien/Title Holder Contractor Reg. # >�� N X'��; -°7.•
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - ConneA to New Septic Existing Septic. Connect to Sewer System
Name of Sewer System '�-� Z
PARCEL INFORMATION- 12 Digit Parcel No, I Z X as S) 0 7_/ Fire District
Legal Description
Site Address(Please include street name, street number and city) 121S
Direr ions to site
RA%Ai z AjSM at
is p pertythin 200'of Saltwater A/ Lake River/Creek �✓'n Pond 0
Wetland 0 Seasonal Runoff —Stream Slopes or Bluffs > 15%
i
TYPE OF JOB - New Add Alt Repair Other Use of Building
Location of Fixtures/Units- 1 st Floo 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric_LPG—Natural Gas Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace 1
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 I
Hosebibs I Dryer Vent 1
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.
PROO OF INUAT N OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Dater L i?oy 4
Owner/Owners Represe ive/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by-al_Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group Type 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
Violation Fee TOTAL FEES
MASON COUNTY rtrsmi i ivt�.
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
On the we co.mason.wa.us
APPLICANT INFO AT N CONTRACTOR INFORMATION
Owne 0 Company Name
Mailing Addre - L Mailing Address Z�
City v ,' State-W-&Zip Code 9 f 3 d.3 City _j N+A State Lew- Zip Code UM
Phone 3 Vy 'S It SG 0/ Other Ph Z Phone 36nV 1 L 0 sD Other Ph
Lien/Title Holder Contractor Reg. # f1 t.,, A(i � vl -0 7•077
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connegi to New Septic Existing Septic. Connect to Sewer System
Name of Sewer System a► 4--! Z
PARCEL INFORMATION- 12 Digit Parcel No, I Z X 02 S9 6 7 r / Fire District
Legal Description
Site Address(Please include street name,street number and city) S
Direc ions to site 1 W
5 t A-v6n
Is p pertyOthin 200'of Saltwater' AJ Lake 0 River/Creek �'n Pond �p
Wetland d Seasonal Runoff Stream Slopes or Bluffs. 15%
TYPE OF JOB - New Add Alt Repair Other Use of Building Zapkc
Location of Fixtures/Units- 1st Floo 2nd Floor Basement Gara a Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS
Type of Fixture No.of Fixtures Fees Fuel Type:Electric_LPG—Natural Gas Heat Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace I
Bath Tubs 1 Heatpumps
Showers ` Spot Vent Fan
Water Heater Propane Tank
Clothes Washer I Gas Outlets
Kithen Sinks 1 Wood/Gas/Pellet Stove
Dishwasher ► Kitchen Exhaust Hood I
Hosebibs I Dryer Vent 1
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.ff 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.
PROOF OF NUA N OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Dater-� .?oo f,
Owner/Owners Repress ive/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by:w Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Grou T e 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
Violation Fee TOTAL FEES
MASON COUNTY rtrsivu i ivv.
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
On the web www.co.mason.wa.us
APPLICANT INFO AT N CONTRACTOR INFORMATION
Owner Company Name •
Mailing Addre Mailing Address Z
City State Lvd-Zip Code 9 t 3 6.3 City L I•••A State—LcA' Zip Code 42X& _
Phone 5G o/ Other Ph Z Phone 3166Yt Z L7 TV Other Ph
Lien/Title Holder Contractor Reg. # �•� w " -07•e
E mail address E Mail Address
Drivers Lic.# DOB &j - Drivers Lic.# DOB
SEPTIC INFORMATION- Connegi to New Septic Existing Septic. Connect to Sewer System
Name of Sewer System —
PARCEL INFORMATION- 12 Digit Parcel No. I Z S I 0 7_/ Fire District
Legal Description
Site Address(Please include street name,street number and ci ) 12.1 41 A S
Dire c ions to site
s e A_576n
Is p pertythin 200'of Saltwater -ti` �e' Lake River/Creek -►�` Pond
Wetland d Seasonal Runoff A/a Stream Slopes or Bluffs> 15%
TYPE OF JOB - New Add Alt Repair Other Use of Building Zapllc
• Location of Fixtures/Units- 1 st Floo 2nd Floor Basement Gara a Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric_LPG_Natural Gas Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace 1
Bath Tubs 1 Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer I Gas Outlets
Kithen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood I
Hosebibs 1 Dryer Vent I
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDEER 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 OO OF NUA N OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Date: %1. L .?on lr
Owner/Owners Represe 've/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTAL REVIEW APPRO ED DENIED NOTES
Building Department
Occ Group T e 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
Violation Fee TOTAL FEES
02/23/2006 09:39 3603960954 PAGE 11
I zZ q7?5go331
Peninsula Light Co .
a. mutual corporariun
A,PPUCatlion for Water AvaUabaffy&Seryke at 121 E Rator Place,Beyb r, WA 9852.8 WaW Systefa
owmd by PLC
Please compote and fetum to:
Peninsula Ught Company Water Services
PO Box 78,Gig Haibor,WA 98335
(253)057-1511 fare(253)a57-1590
Name of Applicant Then boons
Status of Applk;ant Developer , Contractor— Owner,(,.(check one)
owner's Nome Thell Rooney
owners Mailing Address: 1267 NW Mirage LN#8-203
City Silverdale State WA zip 98M
Sits# Tax ramel 0
Site llddren: 121 E Rasor Place
City t3eMair State WA zip gem
Appidxfnt Address hf
city State ZIP
981-5801 Work Phone: ( )
lfofna Phone. (3so )
Typo of SerAw. ResMenthd X Corm mclid _ Other — (check one)
Number of Ufdts(s)and/or Skfgle Fm* Duplsx or MuwFemlly Commerdw
boAkUng alp foovge ik Population
estimated population to _3 Bedroom house sq.it-
genre if cornnweial
Condkions of Sarvice: trailer or mobile
1. Unless oewwlee agreed upon in writing.only one*4e family unit may use a water service. Arty ouax�dirfg,
unit housing a separate familyte or nant fffay be considered an additionalwater sestraN be and remain responsible for all proper
2. Unless otherwise Wood upon In wrung,the owner of the property being served
charge,. This W.K apply even in go event Peninsula Ught Company(PLC)bills a tenant directly.
3. Owner shall complete a PLC Ctw*Ve jm or ow�l of�8r.which may affect the quality,quantity O pressure of the
irrsiantoneous diamond of'affgstnon System
water system from the Site APpmW Ust shall he Installed.Baddlow assemblies must
4. If dimeW by PLC a bacdow pfotsction
be tested by a state Certified Bacdlow AWMtAY Tester(BAT)alter instvAntion,relocation or repair,and annually thereafter.
5. PLC is responetble for services to and hd m ft meter and any check valve. Where a check valve is installed,aUstomer shalt
be responsible for wvdalhdion and nu tenanoe of any required pressure reducing valves.
6. PLC is not meponslbo for pressure toes beyond the meter.
7. The rules and regulations gpvemsd by the W=Mnillon state Department of Health set forth the duties and 013699110es of both
customers and PLC. application fee must be paid piton to ie dnq the oerNCOO of water
a Connection tee,meter inetdlotion fee and
avali r ohay. These fees rarY bye.is ws a led�o� For existing UWAOSs the charges will begin the day of
S. Wear charges begi Vre
legal posseesk //. I
Applicant Signature Date: Z
NOTE: Nrn"of does not a csrtl�sitf9 "Sau . if A WiRmte CM rot the fw wlf!be IgfiMndsd in lUr.
it wN normagy take up to a week to pmom certMkW*
Mr
r
T
Ei NE - Building Permit Information Form - 2318 Plan
This form contains the information you'll need to complete your building permit packet. We've included information for all counties,
some of it may not apply to yours. If you have any questions, please give us a call at 360-807-1849.
Applicant/Owner/Contact Information: Your name address phone number
Contractor Information: Name: HiLine Homes of Elma
Address: 50 Enterprise Ln Ste 215
Elma Wa 98541
Phone: (360)482-1750
License# HILINH*981BT
Expiration: 01/30/06
Tax Parcel#/Assessor's Acct.#: This will be with your property information.
Job Site Address: Your new home address(example:xxx Filmore St.)
Legal Description: This will be with your property information. (example:Lot xx Large Lot Sub Division xxx in Lewis County etc.)
This will be a New Single Family Residence
Describe work/Type of Job: New Home construction
Home Information: Floor Area:(sq.footage)
Main/1st: 2318 #of stories: 1 Carports: 0
Second: 0 Bedrooms: 3 Decks: 0
Basement: 0 Bathrooms: 21/4 Porches: 96
Total: 2318
Garage: 598 (Attached)
Construction Method: Wood frame
Heating System:
Be sure to choose the information below that correlates with the heat system you have ordered.
HVAC/Mechanical Contractor is the company installing your heat system.
Cadet/Wall Mount/Zone Heaters: Standard heats stem
Installer: North Pacific Electric Contact: Bernie/Kim
License#: NORTHPE994JB Phone: 360-943-6020
Expiration: 04/01/04 Location: Olympia
Manuf: Brand:
Module#: KW: 13.5
WHF: AMPS: 20
On permits,for the#of wall heaters,put 1,or you'll be charged extra for every one.
Heat Pump w/furnace w/HWH:
Installer: _Chehalis Sheet Metal Contact: Dave Pyles
License M CHEHASM252MH Phone: 360-748-9921
Expiration: 07/02/04 Location: Chehalis
Manuf: Trane Module: 2TWR1030A1000A KW: 10
Tonnage: 21/2 HSPF: 7.75 Seer: 10
LRA: 73 Efficiency: 100%
Natural Gas or Propane furnace w/HWH
Installer: Chehalis Sheet Metal Contact: Dave Pyles
License M CHEHASM252MH Phone: 360-748-9921
Expiration: 07/02/04 Location: Chehalis
Manuf: Trane Module: TDE060A936 Watts: 977
BTU: 60,000 Efficiency: 80%
Spot Vent Fan:1_ Kitchen Exhaust Fan:_1 Dryer Vent:_ Wood/Gas/Pellet Stoves: 0 Gas Outlets:_
Plumbing System: Installer: Allied Plumbing Contact: Roger
License#: ALLIEP*986KC Phone: 360-289-4114
Expiration: 05/31/06 Location: Rochester
Toilets:_ 3 Bathroom Sinks: 3 Bath Tubs:_ Showers:_2_ Kitchen Sinks: 1 Water Heater:_1_
Clothes Washer:_1_ Dishwasher: 1 Hose Bibs: 1 (first 4 enter quantity of 1,every home has 2)
Energy Compliance Information:
Compliance Method/Path:Always#3 (Per Washington State Energy Code)
Total sq.ft of glazing(glass): Standard home: 265.5. w/sliding glass door option: 282.5 divided by
total sq.ft.of heated area: _2318 equals a glazing percentage of 11% standard or 12% w/sliding glass door option.
Swinging doors and skylights are not counted in this configuration because they meet all requirement minimums.
Window Schedule: See attached form.
Ventilation System:
Interm*ttenUy_Qperaffng Whole House Ventilation System using exhaust fans&wffindow fresh air vents.(VIAQ 303.4.1)
House Fan Specifications: Whole house fan:Qty: 1 Manuf:QuieTTest Module#: QT130 CFM: 130
Bathroom One-Bulb Heater/Fans:Qty 3 Manuf: Solitaire Ultra Silent Model#: 162 CFM: 70
Copyright 2003 HiLine Homes
L
BLJILDII G
S
Window Schedule
H O M E
HIM NE for 2318 plan
Hiline Homes of Elma
Manufacturer: Milgard Windows Inc. Model: Style Line Series
Type: Vinyl U-Value = .35
Windows
Quantity Size/Handing Glazing area Total S . Ft. Location
width x height
1 5'0 x 5'0 25 25 Den
1 5'0 x 5'0 25 25 Bedroom 3
1 4'0 x 4'0 16 16 Bedroom 2
2 2'6 x 5'0 125 25 Great Room
1 6'0 x 5'0 30 30 Great Room
1 6'0 x 5'0 30 30 Media Room
*1 6'0 x 4'0 24 24 Master Bedroom
1 TO x 3'0 9 9 Master Bath
1 TO x 30 9 9 Utility Room
2 2'6 x 5'0 12.5 25 Dining Room
1 2'6 x 5'0 12.5 12.5 Dining Room
2 2'6 x 50 12.5 25 Dining Room
1 TO x 5'0 10 10 Entry
Total glazing area 265.5 sq.ft.
265.5 - 2318 = .114 X 100 = 11%
Glazing Area + Conditioned floor Area Glazing Percentage
* If a sliding glass door option was chosen, switch the appropriate window wl the sliding glass door
and use the calculation below.
1 6'0 x 6'10"s d 41 41 Appropriate Room
282.5 2318 = .121 X 100 = 12%
Glazing Area + Conditioned floor Area Glazing Percentage
All other doors,windows&skylights do not need to be calculated do to the fact they meet all minimum requirements.
I
i
i
6
BUILDING
r---- Detach And Display Certificate --�
j
DEPARTMENT OF LABOR AND INDUSTRIES
IN i
REGISTERED AS PROVIDED BY LAW AS
CONST. CONT GENERAL
EFFECTIV
' HILINE HOMES -
11306 62ND AVE E
' PUYALLUP ,WA 98373
i
f'623-03�-txt0(8/97) ^
'— Detach And Display Certificate —
I -
Mason County Permit Assistance Center
Planning Intake Checklist
Owners Name: Date: b
Project: Reviewed By: _
Commercial Development: YES O ents:
Planner: GBM TSC CMM KJM SNG PBC i
Sit lan:
h Arrow ^
Property Dimensions:
eets and Driveways Shown. Road name:
tAN�11/ Existing Structures shown with setbacks
�11 Location, Septic and Drain-field Shown with setbacks
a�Identify all surface water(streams,ponds, shoreline,wetlands, etc.)r--.A�
u,'fopography(slopes) 00*-L —
ul_�r4osed Structur Setbacks (Direction/Setback): W
F: R: s / S 1: 7r�rzb S2:
Utilit d Drainage Easements- Ye-, I o if yes enter condition#5022)
` er Easements �� F rt,Y 4Ost 0 s .U►'`d
m/Accessory Appurtenances '„'
M-(�ounty Access Permit Needed(add condition#0010)
ee d condition#0020)
Standard Conditions to be added to all Building permits that planning reviews: #5019 and#0700
Are there any impediments that may restrict access to your site? (dogs/gates)
Shoreline and Planning Info
Setbacks: Shoreline: Slope:
Shor ine Designation: Comprehensive Plan: Rura oning-
ot Applicable ❑ Agricultural RR 2.5 V 10 20
❑ Urban ❑ In-holding ❑ RMF
❑ Rural ❑ AFL ❑ RC 1 2 3
❑ Conservancy Vkural ❑ RI
❑ Natural ❑ RAC ❑ RNR
❑ Unknown ❑ RCC-Hamlet ❑ RT
❑ Urban Growth Area ❑ MPR
❑ Unknown ❑ Unknown
Water Body(type of water if unnamed):
SEPA: Yes No own
Flood Plain: YES Uown Map#
Aquifer Recharge: YES CIO Unknown Map#
Tags/Cases: 50 2
RLC/SPI Case: 6-Year Dev. Moratorium: YES
Eagle Nest Tag: UY O Other YES SO
Addressing: Check box if needed ❑ Reviewed by:
Revised:11-01-2005 I:\PLANNING\PAC\PLANNING INTAKE
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
January 20, 2006 PO BOX 1666 Shelton WA 98584
Shelton (360)427-9670
zooRt� Fax (360)427-8442
Elma (360)482-5269
Belfair (360)275-4467
Case No.: BLD2006-00023 Parcel No.: 122077590331
Dear Applicant:
Your building permit cannot be approved by Mason County Environmental Health until the
following are completed and turned in:
Application for Water Adequacy
Please see comments at the end of this letter.
Please call me at (360)427-9670, ext. 554 if you have any questions.
Sincerely,
Trish Woolett
Environmental Health
Mason County Health Services
Comments: need water adequacy filled out completely, signed my manager and
proper information filled in. tw
1/20/2006 1 of 1 BLD2006-00023
PLANNliv -Q-
APPROVED
s_ MASON COUNTY DCD PLANNING
a' SITE PLAN REQUIRED TO BE ON SITE
CHANG S SUBJET TO APPROVAL
By DaWlft7
Obi �
130
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3
'WA
st IT ko 17��
zp 9t Zo or� �
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07)59 0331
C3(oaf 9N -.S&no/ 0 4,0698-002,? r
�k
MASON COUNTY
DEPARTMENT OF HEALTH SE VtIC ENVIRONMENTAL
Environmental Health EMI EA LTH
Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427_9670
Application for Determination of AdequacyBEL FAX( )2767
AX
(360) 27 77s8
Instructions
�. Submrt.corn eCed a � �l�g'to tlYe 4�� =9 dtr�d'Gatro with attacl}ments t9 the health de artment far review....
PART 1: APPIicanVP,arcel Ide tification
Name of Applicant
�� "�• G 1',
Mailing Address 6 " Date
Telephone 36y
Assessor's Parcel Number 12 2
Type of Water System (Check One):
Reason for Application(Check One):
G—Pablic/community water system(2 or
more connections)
❑ Individual well(one connection) 1l— iuldir'g permit
❑ Well ❑ Land use application,if so...
❑ SPring/surface water ❑ Division of land
❑ Other(explain) #of parcels?
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:
Name of Water System Public Water S stem
Water Facility Inventory(WFI)Number:
0 The water purveyor has filed a letter
13 granting blanket hookups to this water system.
11 the manager of this water system.
presently connections m use. This will be ter the has been approved for
willingto connection. r� services. There are
prsta a water to this(these)connections without eceeding the limits of the water system e an
limits set by state and local regulation. t is able and
Signature of Water System Manager y
Date
Update:Match 22,IM
02/23/2006 09:39 3603960954
PAGE 09
CERTIFICATE OF WATER AVAILABILITY
PART A-TO BE COMPLETED BY APPLICANT
PROJECT ADDRESS 1Z RaS P l_�; APPLICATION No.
SUBDIVISION/PROJECT NAME ZI✓ Ike PARCEL I ZZ O72,0 03?1
Proposed water usage 1 (#connections)
Customer type(circle one)1ural residents Residential Mufti-family Commercial Industrial
I, the undersigned, or my appointed representative have requested the following purveyor to certify willingness and
ability to provide the indicated service. I have read and understand the information provided by the water purveyor
on this Certificate, and acknowledge that the proposed project may require improvements to the water system,
which would Incur my financial obligation. Prior to final approval for construction of the water facilities, it is
understood that a legal contract between myself and the water utility,which specifies the terms of water service,
operational responsibility, and financial obligation, may be required.
PRINT --,,
NAME_ r l4#f if!!5>?� SIGNATURE
ADDRESS_ 1 •7 6 7 /V 4- /"JeT-5 Z tn 6ZdZ CITY S,l�il� STATE W ZIP 98,783
NOTE_ Peninsula Light Company requires that an Application for Water Service be completed prior to issuance of a
Certificate of Water Availability. Please contact the Water Department at(253)857-1511 for an Application farm.
PART B-TO BE COMPLETED BY WATER PURVEYOR
Water system to provide service L ZOW P/mow State ID# D 3'73 3"6-
The proposed deveiopmeqo Is not within our approved service area(circle one).
This water utility0w.11 not be providing service(circle one).
This water system*is*l snot esigned to handle Irrigation/sprinkler systems(circle one).
Approved number of connections V 1116 Existing source capacity 30 (gpm)
Number of currentlexisting users S— Existing storage 996 (gallons)
Treatment provided? Yes lIZ4�plrr le one). Water quality concerns: ou> lar„i
Water service will be provided by: * 4P'P,-M-44 j-4w 7 C -n^1A' �
li' Direct connection to approved,existing water main.
Extension of existing water main(s).
New water system In accordance with WAC 246-290 and Pierce County Ordinances 86-117S3 and 92-99
Are water system facilities approved according to DOH requirements? /'nae-Vy>, Cok—
Water service will be made available to this project by(date)_C7Ajs,. 121& I'fol A&kt-6AIlef
"Providing outdoor water use/s reasonable and not during peak demand periods.*
ZJdepbWste#f6mmhnter availabAfty form.doc Page 1 of 2 Rev.April 2003
02/23/2006 09:39 3603960954 PAGE 10
CERTIFICATE OF WATER AVAILABILITY
PROJECT ADDRESS 'LI� 9 'p,
�, �� � Qe uzy�' APPLICATION No. ��
SUBDIVISION/PROJECT NAME Z y P&CG PARCEL
FIRE FLOW INFORMATION(FOR ALL, PROJECTS-SINGLE FAMILY RESID AL, MULTI-FAMILY.
COMMERCIAL OR INDUSTRIAL WATER MAINS):
Location of nearest main capable of supplying at least 500
If not in street at front of property,dista m property to above main is feet.
Fire flow available at 20 psi is gpm for minutes.
Estimated static pre re at project location is psi. IV 1A �rt -flow�
HYDRAN /zoo 6i v e► / 07911,4 45
�c G G.rA�+ �yJtGf-.►
nce from center line of property frontage to nearest hydrant measured along routes of fire apparatus travel
is feet Hydrant number
THE AMOUNT OF AVAILABLE FIRE FLOW INDICATED ABOVE IS IN ADDITION TO REQUIREMENTS FOR
NORMAL DOMESTIC MAXIMUM USE,
A WATER SYSTEM VICINITY MAP WHICH SHOWS THE WATER MAINS AND HYDRANTS SERVING THIS
PROJECT IS REQUIRED FOR All PROJECTS.
A con /has not been signed with the applicant for water service. (cirde one) a-Vo7et P
The above information is an accurate account of the existing or necessary water system facilities. U
FOR PRELIMINARY SHORT PLAT OR SUBDIVISION:
We understand that this document, in absence of a legal contract, constitutes certification of willingness and ability
to provide water service. It is further understood that, in the absence of an approved comprehensive plan,
additional engineering approval has been obtained which demonstrates that facilities to provide water service to
this project are available or can be constructed.
Water Purveyor Date
Signature Title Phone
FOR FINAL SHORT PLAT,SUBDIVISION,BUILDING PERMIT,SEPTIC DESIGN:
We, the undersigned water purveyor, certify that we will assume full operational and maintenance responsibility for
the above water system,which has been designed,approved and installed'in accordance with Washington
Administrative Code 246-290, RCW 90.44(Water Rights Permits), ,
and an approved water system comprehensive plan.
Water Purveyor Peninsula Light Company Water Deaartment
Slgnature��� A& Title Phone Z$_J,837-
"A Bond or Assignment of Funds(please Mach)is acceptable for final land division applications only.
t This certificate of water availability is only good for three years from date issued unless connection fee is paid in full.
Z:/d Vwater/foRnsMatar availability form.doe Page 2 of 2 Rev.April 2003