HomeMy WebLinkAboutCOM2007-00025 Replace One Damaged Piling - COM Permit / Conditions - 3/29/2007 n
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I
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO_o" V 00
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar- P.O. Box 186, Shelton, WA 98584
Shel o (36 427-96 0 • Belfair(360) 275-4467 - Elma (360) 482-5269
e web www.co.mason.wa.us
APPLICAN INFORMATION CONTRACTOR INFORMATION
Owner Company Name
Mail' Address Mailing Address
City v State WA Zip Code 1`15 City State bs''V— Zip Code
Phone Other Phdb,4 q 7— o 7a 4/ Phone 744 kXSQff&j0 Other P
Lien/Title Holder Contras r Reg.# Exp.
E mail address_lqC T'z7 5 E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC /W R SYSTEM INFO TION - Connect to eptic EA Septic
Connect ater System Name of Water Syst
ol
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address(Please include street name, street mb rand city)
Directions to site
Will timber be d sold in par eparation?Yes/No
Is prope i hin 200,of S ater Lake River/Creek :�Pond
We Seasonal Runoff Str m Slopes or Blu
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Oth r PRItW AES ENCE ❑ SEASONAL ❑
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor d Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME IN ORMATION - Make Model Year
Length Widt erial No. No. of Bedrooms of Bathrooms
Type of Heat Pu 'rchase P Replacement Yes/No
Installer Na 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 1 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 pro pert and structure for review and inspection.This permit/application becomes null & void if work or authorized construction is
not comm nce 1thin 180 days or if truction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY
M O OGRESS TIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WIL INVALIDATE THE APPLICATION.
Date:
Owner r R p es ive/Contractor (indicate which one)
FOR OFFI A USE BE OND THIS POINT Accepted by: LAD& Date Z o
DEPARTMENTAL REVIEW APPROVED DENIED @ 14 NOTES
Qf
Building Department
Planning Department
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Ins ection
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 Nb_
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
APPLICANT INF MATION CONTRACTOR M
ORMATION
Owner `' Company Name "
MailingAddress Mailin Address] 71 X ,
5 :.6, City 7 State try" Zip Code
City 0State !�'c� ZipGode `' y
<. '` f= ' - . , W � Other
Phone. Other Ph�n �� � !;�� Phone��-„ �,,, ���=�
Lien/Title Holder
7 .„ ,, �� . .��C Contractor Reg. # Exp.
�-��-�
E mail address E Mail Address
Drivers Lic.# �-�'" DOB Drivers Lic.# DOB
SEPTIC /W ER SYSTEM INF TION - Connect to eptic E g Septic
Connect ater System Name of Water Sys
Well Sewer System Name of Sewer"System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address(Please include street name, street nymbe and city) �`'> '� �' ' l``` 4
Directions to site
Will timber be p"d sold in par eparation?Yes/No
Is proper ithin 200'of S ater Lake River/Creek Pond_ �^-
I Wetlarl Seasonal Runoff Str am Slopes or Blu 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair O h r_ P MA • SJ,DENCE ❑ SEASONAL ❑
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1 st Floor d Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
' Garage Attached Detached Carport Attached Detached
k MANUFACTURED HOME INFORMATION - Make �w Model Year
Length-Widt `Serial No. No. of Bedrooms of Bathrooms
Type of Heat Purchase Replacemen . Yes/No
Installer Na Certification No.
j 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
at the information provided is accurate and grants employees of Mason County access to the above
agent on owners behalf, represents th
described propert and structure for review and inspection.This permit/application becomes null &void if work or authorized construction`is
not com nce ithin 180 days or i c 7
truction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
i ME6� OGRESS I ACTIVITY OF THIS PERMITAPPLICATION OF 180 DAYS WIL INVALIDATE THE APPLICATION.
Date: �
► --
Owner/ er Rt p es five/Contractor (indicate which one)
I
FOR OFFICIA USE BEYOND THIS POINT Accepted by: l. Date (�
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department I �
Planning Department d
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee PlanningReview Fee
fMechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
MASON COUNTY PERMIT NQ.U
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
APPLICAN INFORMATJOKI
CONTRACTOR INFORMATION
Owner Company Name
Mailing Address 'TTSrat a Mailing Address .. " a
Cit State Zip ode City State � '�" " Zip Code
Phone a Other Ph - o 7�4` Phone 4C) Other Ph0+6-099 .
Lien/Title Holder ,*' Contractor Reg. # Exp.
E mail address 5- E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC L W ER SYSTEM INFO TION - Connect to eptic E " Septic
Connect -ter System --,'-Name of Water Syst
Well Sewer System Name of Sewer'System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address (Please include str et name, street nymb r and city) _ t rut',7- 7- u�l.
Directions to site �� 6 " 1
Will timber be d sold in par eparation?;Yes/No
Is proper�,c�wi hin 200'of S ater Lak River/Creek �9/
Wetlaf Seasonal Runoff Strm Slopes or Blu
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Oth r PR MA 1 SPENCE ❑ SEASONAL ❑
Use of Building Describe Work
No. of Bedrooms No. of Bathrooms Square`Footage- 1 st Floor d Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME IN ORMATION - Make Model Year
w Length Wi It erial No. No. of Bedrooms of Bathrooms
Type of Heat Purchase P " Replacement Yes/ No
Installer Na 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 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 proper and structure for review and inspection. This permit/application becomes null & void if work or authorized construction,is
not comm nce ithin 180 days or if truction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
M O A OGRESS TIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WI L INVALIDATE THE APPLICATION.
Date: ? >
Owner/ er R p es ive/Contractor (indicate which one)
FOR OFFIC A USE BEYOND THIS POINT Accepted by: __ ' 1 Date �-
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department 5 17 '
Planning Department
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee _ ,b Site Inspection
Plan Review Fee l3 • 0 V EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood /Gas/ Pellet Stove Fee State Fee
Violation Fee 0 0 KOO 6nPre-Paid at Submittal
Valuation $ TOTAL FEES
BUILDING
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THIS PARCEL
INCLUDES
PLANS, BLUEPRINTS
OR OVERSIZE
IMAGES
LARGE ' FORMAT
IMAGES HAVE BEEN STORED IN
FILE CABINETS) UNDER
PARCEL NUMBER
PARCEL # 3222g0
CASE # 2007- pa0zs
Mason County Planning Intake Checklist
Owners Name: Date: --;
Project: Reviewed By:
Commercial Developmen • NO Comments:
PLANNER: GBM TSC M KIM PBC RDH ,
Site Plan.
----�' �
Li North Arrow
o Property Dimensions: X U
o Streets and Driveways Shown. Road name:
o All Existing Structures shown with setbacks
o Well Location, Septic and Drain-field Shown with setbacks
❑ Identify all surface water (streams, ponds, shoreline, wetlands, natural or historic drainage,
i defined drainage ditches)
o Topography (slopes)
o Proposed Structure Setbacks (Direction/Setback):
F: / R: _/ S1: / S2: /
❑ Utility and Drainage Easements: Yes No (if yes enter condition #5022)
o Other Easements
❑ Accessory Appurtenances: Propane / Heatpump
o Variance applied for: Yes / No - parking spaces allotted? Yes / No
❑ County Access Permit Needed (add condition #0010)
o State Access Permit Needed (add condition #0020)
Standard Conditions to be added to all Building permits that planning reviews: #5019 and #0700
Site Access: Are there any impediments (dogs/gates) that my restrict access to your site?
Is the site clearly marked? How? ❑ Address
❑ Name
Critical Areas: Q Other:
Setbacks: Shoreline: Slope:
Shoreline Designation: Comprehensive Plan: Rural Zoning:
❑ Not Applicable ❑ Agricultural ❑ RR 2.5 5 10 20
❑ Urban ❑ In-holding ❑ RMF
❑ Rural ❑ LTCFL ❑ RC 1 2 3
❑ Conservancy Q Rural ❑ RI
❑ Natural ❑ RAC ❑ RNR
Q Unknown ❑ RCC-Hamlet ❑ RT
❑ Urban Growth Area ❑ MPR
❑ Unknown ❑ Unknown
Water Body (type of water if unnamed):
SEPA: Yes/ No Unknown Flood Plain: YES/NO Unknown Map#
Aquifer Recharge: YES/NO Unknown Map#
Tags/Cases:
RLC/SPI Case: 6-Year Dev. Moratorium: YES/NO
Eagle Nest Tag: YES/NO Other YES/NO
Revised: 09-29-2006