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P€..� 3N au 6tuFaT Div By m F- gY cor u AsMC7Af let [.tic o t I t 8 o kl2k 1vq KLS � r _ AmE fit.LED. 01101Ao >� " G �1 -- � fi AD Ae`eamy— I t� os t t Aw Ar " c� rz t ' of � o r J J N_ �cam i ky a71 W l c 00 i �. 7 Q „ 4ING Mason County Permit Assistance CAN Planing Intake Checklist Owners N-6� Date: �e ' d,9 " b Project: Reviewed By6k_) Commercial Devel nt: YES Comments: Planner: GB T_!A�M TSC JLW Site Plan: • ' =pertyrloim rensions: `t_X ) 3_1 Streets and Driveways Shown. Road name: _ C-) L,4M t� All Existing Structures shown with setbacks �( Well Location, Septic and Drain-field Shown with setbacks 01Yl YY1 , Identify all surface water(streams,ponds, shoreline,wetlands, etc.) Topography(slopes) ❑ Proposed Structure Setbacks (Direction/Setback): F: j /a o R: 9 1;Sl: S2: / �J }q Utility and Drainage Easements: No (if yes enter condition#5022) 'iW Other Easements sa Accessory Appurtenances ❑ 6 YR TIP Shoreline and Planning Info Setbacks: Shoreline: Slope: Shoreline Designation: Comprehensive Plan: Rural Zoning: X Not Applicable ❑ Agricultural ❑ RR 2.5 5 10 20 ❑ Urban ❑ In-holding ❑ RMF ❑ Rural ❑ LTCFL ❑ RC 1 2 3 ❑ Conservancy ❑ Rural ❑ RI ❑ Natural ❑ RAC ❑ RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT _X, Urban Growth Area ❑ MPR ❑ Unknown ❑ Unknown Water Body(type of water if unnamed): SEPA: Ye z::9 Unknown Flood Plain: YES NO nkno Map# Aquifer Recharge: YES NO Map# Tags/Cases: --� RLC/SPI Case: 6-Year Dev. Moratorium: YES Eagle Nest Tag: YES 4n Other 140 � Q� Addressing: Check box if needed Reviewed by: ❑ County Access Permit 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 Revised:(-22.00 Mason County Permit Assistance Center Pldkning Intake Checklist Owners Nam (**(,t -- 4 ff ---'- Date: -L' C( Project: Reviewed By: Commercial Develo O.i Comments: Planner: SAL GBM DMJ TSC Site,Plan: North Arrow 'a Property Dimensions:_ � D �( X I J Streets and Driveways Shown.Road name: 0 .13 �� z with setbacks Identify all surface water(streams,,po shoreline,wetlands, etc.) — -- -- E✓ h (slopes) 1 C-� Proposed Struc Setbacks /a (D on/ �back): _ 7� F• R. �c S 1• (,u� S2: r / ,, �Uather tility and Drainage Easem es No (if te condition#5022) Easements Accessory Appurtenanr a County Access Permit ed( =20) 10)o State Access Permit condition Standard Conditions added to all Building permits t planning reviews:#5019 and#0700 Shoreline an lanning 0 Setbacks: Sho eline. Slope: Shoyel esi tion: Comprehensive P Rural Zoning: Not bl ❑ Agricultural 0 RR 2.5 5 10 20 ❑ Urban In�olding RW 0 Rural ❑ CFI, ❑ RC 1' 2 3 ❑ Conservan ❑ Rural ❑ RI 0 Natural ❑ ❑ RNR ❑ Unknown 0 et 0 Ur Area 0 0 Unkn wn nlrnown Water Body(type off=- SEPA: Yes (! '' 'Unknown Flood Plain: YES Unkno Aquifer Recharge: YES N U ap# Tags/Cases: _ RLC/SPI Case: 6-Year Dev. Moratorium: YES Eagle Nest Tag. YES NO Other YES (1' Addressing: Check box if needed .0 . Reviewed by: UVIRM 12fWM3 Request To Revise An Ian Permit Number: BLD200 a - j Name Parcel Number r o��� -S�QC7�jU Phone Number daytime (4�) � a� Project Address Mailing Address Plea pro ' e a complete, detailed description of the proposed revisions to the approved plans: Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No Are the approved site plans included? ❑ Yes ❑ No Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No Is a stamped and signed approval included with this request? ❑ Yes ❑ 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 ❑ No If Yes,Is a revised site plan,.with all new setback dimensions included with this request? ❑ Yes ❑ No Additional Information: Applicant's signatur _ Date: &--29-04— Office use only Received by. Date Sent Assigned To Approved By Date B Original Valuation: $ Additional Valuation: $ bz_ K Sq.Ft. x$ $ n V r Sq.Ft. x$ $ E.H. > Total New Valuation $ P W Additional Fees: Additional Planning Dept. $ Additional Plan Review $ New Setbacks: Front / Rear / Additional Building Permit $ Sidel. / Side2 / Additional Plumbing $ Additional Conditions/Comments: Additional Mechanical $ Additional E.H.Dept. $ Other $ Total Amount Due: $ Amount To Be Paid Up-Front$ TxY LhiY RevbW SRG W2?/2M FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO. PLEASE PRESS HARD BUILDING PERMIT APPLICATION ino 1 l-] 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 INFORMATION CONTRACTOR INFORMATION Owner U- Company Name Mailing Address 12294 12.1 Mailing Address City -f Le J State 00A Zip Code City State Zip Code Phone 42-S•- 37'>t2-7- Other Ph. PM 432 5 t9% Phone Other Ph. Lien/Title Holder Contractor Reg.# C VYxjTt7Rc4 Exp. t/To S E mail address ua►r - Q- U-yw-eA.czru, E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Vb=System Name of# System AAA 5CW cgDO tj Well Water System--4—Name of Water System L-AiciaAA)b U 11. AGE u)2rD9K co,4 PAAL PARCEL INFORMATION - 12 Digit Parcel No. t 221 .o9 Fire District Legal Description t-OT4- >A)0 V t Site Address (Please include street name, street number and city) 72 ©t-XAtate <©uRT 4-LEN WA . Directions to site Sic -&E-D Will timber be cut and sold in parcel preparation?Yes/ Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes 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 Describe Work 'J'aIce 0099IT- 117H5 Plat aos;s-3B No.of Bedrooms3—No.of Bathrooms Z Square Footage- 1 st Floor 211 3 2nd Floor h 3rd Floor X Basement n 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.,o[Bathrooms Type of Heat Purchase Price$ Replacement Unit? Yes/No Installer Name Certification No. OWNER/BULDER 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 aun entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permis- sion from all neces rX parties.If permission is required from any easement holder or any other party in interest regarding this applica- tion or the pro in th plication,I have obtained permission from them to apply for this permit and conduct the work proposed. X _6AAC-1 IUX 5 Date:_ Owner O Hers Representative/Contractor (indicate which one) OR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department A -- Planning Department Environmental Health Department Public Works.Department Fire Marshal _._. FEES . . _ . .... . .... .... .. Building Permit Fee Q L Site Ins ection Plan Review Fee EH Review Fee ' Plumbin & Base.Fee Planning Review Fee Mechanical& Base fee "o Other Wood/Gas/Pellet Stove Fee State Fee �- 5 . . Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES .,,.4 --OOc?17 PERMIT NO. MASON COUNTY PLUMBING/MECHAtOcAL 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 INFORMATION CONTRACTOR INFORMATION Owner. Company Name �- Mailing Addres Mailing Address City tate C.J Zip Code � � City Mate Zip Code Phone h75-4*32---3I2Z Other Ph. 4-)2-"�18$ Phone Other Ph. Lien/Title Holder Contractor Reg.# Z 110ca4 Exp. 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 INFORMATION - 12 Digit Parcel No. 17 2 1 -- — 0011 Fire District Legal Description L4Z 4 L=A�tL ELA Aj b U 1 CiAt,'E h i\/ k I Site Address (Please include street name, street number and city) ?D 00(MFtG- <:0QV-T'- — A--t_,L_`(N,uA Directions to site Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 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 UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electric LPC Natural Ga$_ Heat Pump_ Toilets ape of Unit No. of`Units Fees Bathroom Sink Furnace Bath Tubs 2 Heatpumps Showers = Spot Vent Fan Water Heater I Propane Tank Clothes Washer I Gas Ovkts Kithen Sinks I Wood/0 /13elletStove Dishwasher I Kitchen Exhaust Hood Hosebibs Z- Dryer Vent Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is required from any easement holder or any other parry in interest regarding this application or the work proposed in the application,I have obtained permission from tern to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information provided is to and grants employ of Mason County access to the above described property and structure for review and inspection. PROOF NTINU O W IS BY MEANS OF A PROGRESS INSPECTION. X 1 _ Date: /7J2 C� ' axDer ers i4er)resen / ontractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bid Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Group-Type Constr.- Planning Constr.- Planning Department Environmental Health Department FEES Plumbing & Base Fee Site Inspection Mechanical & Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES MASON COUNTY DEPARTMENT OF HEALTH SERVICES Personal,fealth Environmental Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BBLFAIR(360)275-4467&4469 Application for Determination of Adequacy Instructions t a f; qy lad<aa F+y ••.<" >w,,'a�'srorc• wi•'xv�A!��w•iw,atABk�:•1.:kwFkf; .:: n$i$:a:r. »»»ii•: P t fai%+ a:ev1•�a:kala.:`iM•�,�'i'aa�iM �`•+ N h!e' �c�a�.!do.-1�.,....•.,.. �xAY`•7{Ax:Axya.YAo:,vab"'�".w"asl�!a:«xa:mkrusnA�s:�s�. • �f. 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KA�4:;#'#$.;7{g+�•^;x:x ..AWk:B!"wA::'' i4lk � �{'.l>•tril'i^.•'YR ��`w '• '���.�'tYAMk:f!'M:Aw.:�;O:V'�k.�i�'!x:x'.34A,,:f•..A:<::f':i•A.::'+•.` WAY:►y,a Y• ' � I Aa:aHaafframAl4kaa:owa; a Y>tiV ia:ya �;� •�Ay'f�, s, �g�h�i'.;1<ii,:�e:x:+N:aiA:i;A':9YAJ:Y'•T.:fi2:'at;{:#:kiq` .P.%f:.f.f>1AaN.�• MA M 14+nx4 aalaal R x< x 5�'` �. �li �'� �lf r :auavW:.. ;Aa�::�w @Yi �� Its. l� ij >iti� QI111����°ia�tii�+ �alt�> �'•' PART 1; Applicant/Parcel Identification Name of ApplicantST � ''`'� ' 1 NG Date Mailing Address (3oX Telephone ZS-43'L-312Z M,C'Pl0, V(?,a�, 1 f303 I Assessor's Parcel Number L ►'o LCe..t'1d V c I l&cee-, I Type of Water Sys I Check One : Reason 'or A lication Check One Public/Community Water System(2 or more X Building permit connectlom) a Land use application,if so.. ❑ individual water source(one connection),if so.. a Division of land Q Well 0 of pucels? a Spring/surface water SPH9 - 0 Other(explain) o Boundary line adjustment ❑ Other(explain) 3 {{ 5�•fi i i Ti PART 2; Water System Information 9 Complete the pection appropriate for the type of water system being evaluated for adequacy: ft C 1I'ater 5 stem it Name of Water System Number: Water Facility Inventory(Wpl) 0 The water purveyor has filed a letter granting blanket hookups to this water system. services. Thera are a I am the manager of this water system. The water system has been connections u wa er system is able and presently connections in use. This will be the welling to p"'ro`v'ir3e water to this(these)connections we out exceeding the limits of the water system or any limits set by state and local regulation. i Date '! Signaturc ofVater System Manage N:IWDATAWRcfflU1WAr6RAD3.WP Update:Much 22,IM W - , 11