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HomeMy WebLinkAboutBLD2005-02135 - BLD Application - 12/18/2005 RECEIVED FORM MUST BE COMPLET INK MASON COUNTY PERMIT NO.b4e1;?AC6-=�5 PLEASE PRESS HARD �� IN� (MUDING PERMIT APPLICATION 426 W.fedar- P.O. Box 186, Shelton, WA 98584 \/jo %kio §5�+3 Y70 • Belfair(360) 275-4467 - Elma (360) 482=5269 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner,__b n AA K n iI2he4"' Company Name Mailing Address I Ibi K&mt,:s Dr Mailing Address City . LSia,na State WA Zip Cpde gXZ33 City State Zip Code Phon 9:5 •C20-.24 µ a Other Ph(-aS3)s�h9-112510 Phone Other Ph. Lien/ itle Holder Contractor Reg.# Exp. E mail addresskn j2 b 0 GLD( • LeM E Mail Address Drivers Lic.# tj El 1 DOB I 1 2 Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well ✓ Sewer System r/ Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel Nol boo a Fire District Legal Description -t / u7r'►i Site Address(Please include street name, Vreet number and city)- fQLol Directions to site "Iu t 1D7�h t `l -t_L dSS Drt h t Will Ifiber be cut and sold in parcel pre aration?Yes/ o ;f- 5*yon, ef-UafcQ Gw 4* prp� Is property within 200'of Saltwater Lake River/Creekond Wetland Seasonal Runoff Strea lopes or Bluffs > 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 . Other PRIMARY RESIDENCE ❑ SEASONAL ❑ Use of Building WdPltL S Hv P Describe Work W a _ No. of Bedrooms No: of Bathrooms . Square Footage- 1st FlooL�P7 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. Garage Attached , Detached' Carport ✓ Attached Detached MANUFACTURED HOME INFORMATION - Make 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 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 commenced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS FAPROGRESSINSPE TION.INACTIVITYOFTHISPERMITAPPLICATIONOF180DAYSWILLINVALIDATETHEAPPLICATION. X ' .1 Date: Owner/Owners epresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Fire Marshal FEES Buildinq Permit Fee 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 Valuation $ TOTAL FEES RECEIVED '^ FORM iI+tUSBE OMPLETPFY N iNK MASON COUNTY PERMIT NO, IVUU PLEASE.PFr SS HARD gZILbING PERMIT APPLICATION 0, 1/q0fKSI10+P �W 9,44dar-P.O. Box 186, Shelton,WA98584 0 Belfair(360)275-4467 Elma(360)482-5269 On the web www.co.mason.wams APPLICANT INFOMWTION CONTRACTOR INFORMATION Owner- i n Am k n i ah&' Company Name Mailing Address-loS I ICa.m L&S OY Mailing Address City LStQr,sl state _Zip Code City State Zip Code Phon2:s� X'�9��µ .._Other Ph 5" -82,Sfo Phone Other Ph. Lien/ ►tle Holder Contractor Reg.# Exp. Email add ress-knrT L► An4 -Lam E Mail Address Drivers Lic.# 1 I 9K DOB I/12-[Kag Drivers Lic.# DOB SEPTIC!WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic Connect to Water System Name of Water System Welt ✓ Sewer System,rr Name of Sewer Syste PARCEL INFORMATION-12 Digit Parcel No. r - - boO Fire District Legal Description omn cd cs rvi Site Address(Please include street name, sireet number and c eoi Directions to site nn- o n t W 7kwr ef-06-s Willblinber be cut and sold in parcel pre rati vS� on?Yes/ I- 5*eo,, ei%eAd Gw /V prp� Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Strea lopes or Bluffs 15% Is this permit subrnittal the result of a Stop Work Notice,Correction Notice or other enforcement action?YesfNo TYPE OF JOB- New ✓ Add Alt Repair . Other PRIMARY RESIDENCE SEASONAL ❑ Use of Building 1# — a No.of Bedrooms_ No. of Bathrooms Square Footage- 1st FlooL(PT y 2nd Floor 3rd Floor Basement Deck—Covered Covered Deck Other Sq. ft. Gars a Attached. Detached'-—. Carport Attached Detached MANUFACTURED HOME INFORMATION -Make Model —Year— Le ngth 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 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 t have obtained the permission from all time neces parties.If permission is required from any easement holier or any other party in interest regarr�ng this ap*mbon or the work proposed inthe application, 1 have obtained Qermiss►on from them to apply for this permit and mud the work proposed. The owner or agent,oq owners behalf, represents that the umformation 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 8 void if work or authorized cord*uction is not commenced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS A PROGR INSPE INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: Owner/Owners 4tepresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health 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 i 111.,UCEIVED MASON COUNTY PERMIT NO. �LD �ORM MUST BE COMP IN �p�j — 4'" BE IUD V �bING PERMIT APPLICATION 5 .EASE6 cedar•P.O. Box 186, Shelton,WA 98584 WDf S a 9% •Belfair(360)275-4467• E{ma(360)482=52fi9 On the web www.co.mason.wa.us APPLICANT INFORMAnO�N CORTWC-rOR INFORMATION owner L4 A K tt i o Company Name Mailing Address teat t" ` Or Mailing Address State Zip Code City _State bt____Zip a ��� �---� City Other Ph. p . �' Other P b" - Phone Lienittle Holder Contractor Reg.�. ' gyp• E nj address_ -o E Mail Address FE � # I t DOB I r 2 Drivers Lic.# �B- C I'WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic ct to Water System -Name of Water Syst " Sewer System v, Name of Sewer SFire District ELINFORMATION.12 Digit Parcel No _ - rimtloD t number andedress(Please include street name, I S Directions to site ""''`�'iO �° ri cut and sold in parcel p��aration?Ygs/ 16* s �i' and in 2t)t?'of Saltwater Lake River i Creek5%„ --Seasonal Runoff Strew s or Bluffs 159�0submittal the result of a Stop Work Notke,Cortection Notice orother entorcerrter�t action?YoslNo E OF JOB-New t✓ Add Alt Repair ,Other PRIMARY RESiD=NCE Q SEASONAL of BuNding W.E&K- :iW1 �r Describe Work 11,7 2' 2ndof Bedrooms_:_--No.of Bathrooms Square Footage-1st Floor_:.. .-- ---- 3rd Floor—Basement . Deck _ _ Covered Deck Other - Sq. ft. pa ,�__.___ Attached. . Detached'..., Carport--k� — Attached _.lam— Detached MANUFACTURED HOME INFORMATION-Make Model Year . Na. of Bedrooms______No.of Bathrooms - Len9th�.-�—yy�---Serial No.Type of Heat - Purchase Price$ Replacement Unit? Yes!No Installer Name Certification No. OWNER/BUILDER /4dkriowleds subm{sslon of inforrrtation may result in a stop oak ceder or permit revocarion. is s below.I declare d*I am the owner,owners legal ,or rice ax r.I fudher declare� of such by rgn-A an t have obtained permission watt in rite .l work �do ripe a the #Itat 1 am ettCrUed iiD reoelire ih�permit and i this apple ation in merest regarding rite net�ess�y parries.ff pemOn tram any easement holder a any ocher party The owner or Enot BrnmewVn0cmp8drwty= m die appkaft,I have obtained permission fiom than to apply fo tQs p � the work proposedowners behalf,represents that the information provided is accurate and grants employees of Mason may access bo the orb tiOd for reviaw and inspectiori.Thispeurr>rittion snuU&void if work or authorized construction is cc 180 days or if consmx on work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS A INACTMTY OF TM PERMIT APPLICATION OF 180 DAYS�,INVALIDATE THEAPPLICATK*L X Dat �----- owner 1 Owners tative!Coiitracwr (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by. Date APDEPARTMENTAL REVIEW APPROVED DENIED NOTES Building De rtment Plannin ntment R Health Department Fire Marshal FEES Build( Permit Fee Site Inspection Plan Review Fee EH Review fee Plumb( & se Fee Planning Review Fee Mechanical&Base fee Other R12C IVED =ORM MUST BE COMPLE IN INK MASON COUNTY PERMIT NO.7BL�2�n5-OZI3S 3LEASE PRESS HARD �V WING PERMIT APPLICATION Wo�, p 6 War•P.O. Box 186, Shelton,WA 98584 � 3l 0- Belfair(360)275-4467 - Elma (360)482=5269 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner Llnaa K hi Pw Company Name Mailing Address 1oBI Kamr,tS O' Mailing Address City teJd A Zip Code g3 City State Zip Code Pho Other P 3 ,S - Phone Other Ph. Lien/rifle Holder Contractor Reg.# Exp. E mail addres E Mail Address Drivers Lic.# I I •DOB 1 I t 2 Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Water System Name of Water System WeII 1,1� Sewer System V' Name of Sewer Systelp PARCEL INFORMATION-12 Digit Parcel N . — — boo Fire District Legal Description S h,' 2 3 Aj 1 0. Cd corvi Site Address(Please include street name, eet number and ci rDns to site +► h� t d55 er be cut and sold in parcel pre ration?Yes/ 4, s�,t, �� lvy 4- prf rty within 200'of Saltwater V Lake River/Creek pondSeasonal Runoff Strea lopes or Bluffs 15%permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yss/No OF JOB-New V Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL Building ORES Nod 1 J�escribe Work a No.of Bedrooms-� No.of Bathrooms Square Footage-1st Floot_�7 � 2nd Floor 3rd Fkror Basement _ Deck . _ Covered Deck Other Sq.ft Gara a Attached. . Detached`-,,.-— - Carport—l!:L_ Attached Detached MANUFACTURED HOME INFORMATION -Make Mode! 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 A ckrK wtedges submission of inaccurate information may result in a stop work order or permit revocation. AcicnowledgerrteM of such by signahxe bebw 1 declare that I am the owner,owners legal representative,or the contractor.1 further declare that t am erttBed to receive this perrtd and to do the work as proposed in the application.I declare that I have obtained the permission firm all the r>e sary parties. tf permission is requmed from any easement holder or any other party in interest regarding this application or the work proposed to the application,I have obtained pem►ission from them to apply for this pernit and conduct the work proposed. The owner or property and for review and atrort P is accurate and grants empk�rees of Mason County access to the above describedinspection.This pemrivapplication becomes null 8 void if work or authorized construction is not commenced within 180 days or tf construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY jM:E:AJN�SAPRQGRESS INSPECTION.INACTIVITY OF THIS PERMITAPPUCATION OF 180 BAYS WILL INVAUDATE THE APPLICATION. X Date: owner I Owners presen five Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Ili Building Department Planning Department 1/61 Environmental Health Department Fire Marshal FEES Building Permit Fee Site Inspection li Plan Review Fee EH Review Fee Plumbing 8 Base Fee Planning Review Fee Mechanical&Base fee Other Wood/Gas/Pellet Stove Fee State Fee I RECEIVED Request To Revise An ed Plan NOV 17 2006 �/ Permit Number: BLD200�-0 ! S Name �_i n- L>i4 K n r CEDAR 5T. Parcel Number / /62�y0� Phone Number da ime �S Project ddress 2 1' ;t— Mailing Address kA—"-S k, Please provide a complete,detailed description fonf the proposed revisions to the approved plans: k" L ., d ;K Are two sets of the revised plans or addendum indicating the changes included? Yes ❑ No Are the approved site plans included? E Yes ❑ No Are the revisions clearly and accurately identified on the plans or addendum? i/Yes ❑ No Does the plan contain an engineer's or architect's lateral or vertical analysis? a"Yes ❑ No If Yes,Has the engineer or architect approved this revision? 0(Yes ❑ No Is a stamped and signed approval included with this request? WYes ❑ No (Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.) Does the proposed revision modify the footprint or location of the structure? ❑ Yes 1VNo If Yes,Is a revised site plan,with all new setback dimensions included with this request? ❑ Yes ❑ No Additional Information: Applicant's signatur�*� Date: //Z/Z//ZaZL Office Use Only Received by: Date Sent Assigned To Approved By Date � Original Valuation: S B. 7 Additional Valuation: $ Sq.Ft P' I ] ilN ' �d Sq.Ft x S $ Total New Valuation $ j n%y\— Additional Fees: ❑ Additional Planning Dept. $ tieaat*lan Review $ N RCa gt New Setbacks: Front / Rear / .Additional-Building Permit $ Sidel / S1de2 / Additional Plumbing S Additional Conditions/Comments: Additional Mechanical $ Additional E.H.Dept. $ Other $ Total Amount Due: S Amount To Be Paid UP'Front$ T�ikw vq- ax S2mLA r f � G 110 C.x 1 l 1 ti ly BUILDING - -- --- _ { _ --- - . _. • �act A - ' �� •� � �� 5,�� bey , e t - f • i-• �, r: r --��_-'.Yoe-`-Gt3AR1? �At�- � 271'•; ' • - '":'ram--��'-s.=' -��^� -- - _ •. _ _ -,.-..-��:a�:' -±_ r<�__�. .if;rJ1r.� L� zY IDL �B w ��� C5 � f u F' 3j r tt ( •i tt � t �, ..+..{ ..w --...-+ --•— .r--fat -- t �r. r� � +- .Yr � i. �_. 2540 HWY 302 MELFAIR, WA 98528 LVWOA KNVHER 1061 KAIY US MVE FOX ISLAND, WA 98333 253-549-8286 Ae�+oe1 * 12216-21-00020 Leo bescription: South 140 fact of Gov. , Lot 1 Section 16, Township 22 North Raw 1 W. of WM tying Westw4y of secondary State Hwy No. 148. • y�R'� c 9 I C A Ptttl,i- lSl x M73aZ 4 si t IA 3 so ----------------- is fmm Lt.r� t�ru SITE PLAN REVISION—BLD2005-02135 PROJECT ADDRESS Parcel# 122162100020 2542 E. State Route 302 1"=40" Belfair,WA 98528 1/4 inch= 10 f t. I prefer that you email me any information pertaining to this revision or questiora&ou have. Thank you. �9 Mailing Address Linda Knipher 1081 Kamus Drive Fox Island,WA 98333 F � 253-549-8286 email: Linda.knipher@gmail.com O'L Legal Description: South 140 feet of Gov Lot 1 Section 16,Township 22 North Range 1 W of WM lying Westerly of secondary State Hwy No. 148. pate ••.,;i.•.',_ :J:iJC.l4! L s • 1A AM VGV Grow 1 i II �5 � k . ►! . Oil, cow "Wr sm BELFAIR, WA 9 ..'i.,LMA OWMM a 1M KA*JS cRJ Fox MUM. WA M33 253-549-SM Parcel # 12216-21-00020 Legal besu*#ioe: South 140 feet of Gar. Lot 1 Section 16, TowraMp 22 North Rouge 1 W. of WIN Ift Westerly of seconalary State Very No. 14$. Osu �.r 3 ALA.drt i 3 _ g ,,-Soft IN Lam' `tetra j ... .. . . .. .. 1 Mason County Dept. of Community Development Mason County Bldg. 3 426 W.Cedar P.O. Box 186 (360)427-9670 Local (360)482-5269 Elma Shelton,WA 98584 (360)275-4467 Belfair Notification of Permit Cancellation Permit approved, not Issued May 21, 2007 LINDA KNIPHER 1081 KAMUS DR FOX ISLAND WA 98333 Case No.: BLD2005-02135 Parcel No.: 122162100020 Project Description: CARPORT WITH STORAGE ABOVE Dear Applicant: Upon review of our records, the Mason County Permit Assistance Center has identified that your building permit application has been approved and ready to issue since 01/11/2006. Once approved, permit applications are valid for 6 months. If you intend to obtain this permit, you must make arrangements to do so within ten (10) working days from the date of this letter. If we do not hear from you within the that time, your permit will be cancelled and a building inspector will make a site visit. In the event that your project has been completed and a permit was never issued, you will be assessed penalties as allowed under Mason County Title 14 and Mason County Title 15. If your project has been cancelled or if you wish to withdraw the permit, please notify me as soon as possible at (360)427-9670, ext. 553. If you feel that you have recieved this notice in error please contact me. Thank you for your cooperation. Sincerely, Kim Knapp Mason County Department of Community Development May 21, 2007 BLD2005-02135 Mason County Permit Assistance Center lanning Intake Checklist Owners N e: 1, Date: (a"` q 0 Project: oK Reviewed By: Commercial Development: YES O Comments: Planner: GBM TSC CMM KJ SNG PBC r e Plan: North Arrow f II .r 'Property Dimensions: !� X 1 treets and Driveways Shown. Road name: wr'All Existing Structures shown with setbacks U ell Location, Septic and Drain-field Shown with setbacks topography entify all surface water(streams,ponds, shoreline,wetlands, etc.) (slopes) o' Proposed Struc a Setbacks (Dire tion/Setback): J F: /_R: 0 / S l: S /�S2: 1 /� 9- `7tility and Drainage Easements: es No (if yes enter condition#5022) is ces cress ermit Needed(add condition#0010) State Access Permit Needed(add 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) ©N,�­ Shoreline and Planning Info Setbacks: Shoreline: _ s Slope: Shoreline Designation: Comprehensive Plan: Rural Zonin ElNot Applicable ❑ Agricultural �RR 2.5 5 0 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 ❑ Unknownf1� ❑ Unknown Water Body QXpe of water if unnamed): SEPA: Yes o Unknown Flood Plain: YES N U ap#,. Aquifer Recharge: YES NO nkno Map# Tags/Cases: �D RLC/SPI Case: 6-Year Dev. Moratorium: Eagle Nest Tag: fx=FIS NO Other FSfNO Addressing: Check box if needed ❑ Reviewed by: Revised:11-01-2005 L\PLANNING\PAC\PLANNING INTAKE MASON COUNTY RESIDENTIAL PLANS SUBMITTAL CHECKLIST Owner's Name: Date: 11 SA Reviewed By: Documents: —Planning Intake Checklist Completed, Site plan,includes:Allowable building area,roof overhangs,decks,etc. Fire Apparatus Access Road info required? Yes/No Energy Code Application Form-O Electric wall heater O Electric central furnace O LPG Furnace O Heat pump with electric furnace O Heat pump with LPG furnace O Boiler(heat type ) O Other: Specify: Mechanical/Plumbing Application-WATER HEATER FUEL TYPE Engineering? Yes No Snow load used: Seismic Zone(circle one): D 1 or D2 Geotechnical report or assessment? Construction Plans:_3 COMPLETE SETS K Plans Legible x Recognized Scale Elevation Views dross Section K Foundation Plan Roof Framing Plan Floor Plan-Use of Rooms Noted ;� Floor Framing Plan-all floor levels represented? Loft,crawlspace,etc. Deck Framing Plan,including covered.porch framing Plan Details: X Roof framing details,truss lay-out may be needed 5.4;cL:9rc,,-t h Wall Framing-Does bearing-wall height exceed 10'?(Engineering may be required) Floor framing: Floor joists: Floor beams: V Window headers: Typical header: ;,r- Foundation:footing size,reinforcement k6• r' Concrete Walls-Does Concrete Wall Height Exceed 9'?(Engineering may be required) K Landings at all exits? Less than 30"above grade? N -Heated By Furnace-Location of Furnace Fireplace/Stove Information Shown-Fuel Type?— Window Sizes Marked on Plans 2-Story Garage? (Engineering may be required) R602.10.1, 1ft story of a two-story D145%,D2—55% �C Braced wall panels(shear walls)marked on plans or lateral engineering? (Plans may not be approved if not provided.) COMMENTS: IRREGULAR BUILDINGS(Irregular Shape)R301.2.2.2.2 Irregular portions of structures shall be designed in accordance with accepted engineering practice. A portion of a building shall be considered to be irregular when one or more of the following conditions occur: 1)Exterior braced wall line or BWP cantilevered or offset by more than 4' 2)Roof or floor is not laterally supported on all edges 2A)Portion of roof or floor extend more than 6 ft.beyond the braced wall line. 3)End of BWP extends more than 1 ft.over an opening more than 8 ft in width below. 4)Opening in a floor or roof exceed the lesser of 12 ft. or 50%of the least floor or roof dimension. 5)Portions of floor level are offset vertically 6)Shear wall lines do not occur in two perpendicular directions. 7)When a story above grade is includes masonry or concrete construction(exc:fireplaces,chimneys,and veneer). When this applies the entire story shall be designed.In accordance with accepted engineering practice. 2003 IRC Plans submittal checklist simplified/WORD MASON COUNTY / DEPARTMENT OF HEALTH SERVICES _ Environmental Health Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467 Application for Determination of Adequacy FAX(360)427-7798 Instructions l. Complete Part I. No deteftril on can be`made until Part 1 is fully_cainpleted. 2. Complete.only the portion`ofPart 2 applying to the itype of water'sysiem utilized. 3. Submit completed application,with attachments to the health department artment for review. PART 1: Applicant/Parcel Identification Name of Applicant ',, 4L ✓ Date Mailing Address Telephone Assessor's Parcel Number /2-71 tlo — -Z I" -B � 000Q Type of Water System (Check One): Reason for Application (Check One): Public/community water system(2 or more connections) ❑ Building permit ❑ Individual well(one connection) ❑ Land use application,if so... ❑ Well ❑ Division of land ❑ 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: ublic Water System Name of Water System 2— Water Facility Inventory(WFI)Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ❑ I am the mana er of this water system. The water system has been approved for 0Z services. There are presently connections in use. This will be the��connection.-This-water system is able and willing to prove a water to this(these)connections w1 outh t exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date Update:March 22,1999