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o CONCRETE MECHANICAL MANUFACTURED HOME
N
o Date B y n
rn Footings J Setbacks Gas Piping Ribbons Date
o Interior Date By Interior-Date By bate By (A
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Exterior Date By Exterior-Date B _up
-4 INSULATION
Point Load/Isolated Footings mate By r,
BG I BLAB INSULATION M
Date By Data By FIRE DEPARTMENT m
Foundation Walls Floors Date By
Date By Data 1 Z l C& By DECKS
FRAMING walls Date By
Date O By�- Data By PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attic
ype-
Date By Data _ By Dato By
DWV DRYWALL. Typal
Int Brace Wall
Date By Date By o0
..,
Date By FINAL INSPECTION o
(D Water Line Fire Separation f N
Date B Data ' ., j, , B (. O
Date By y r �• Y >i ; CD
Pass or Request Inspect. o
0 Type of Insp. Fail Date Date Dane By Comments k
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95E COMPLETED IN INK MASON COUNTY PERMIT NO.
FjR ` HARD BUILDING PERMIT APPLICATION
Shelton WA 98584
426 W. Cedar• P.O. Box 186; ,
Shelton (360) 427-906n 0 eB web Irw 360)275- 467 - Elma (360) 482-5269
APPLICANT INFORMATION CONTRAus
CTOR INFORMATION
+ � Company Name �-1 _
Owner CA Mailing Address 5 Z s
Mailing Address iw`�`� —Z City 6t1.�,��' *3 State `.+�Ar Zip Code G 2�3iv
City State VJA' Zip Code Phone �r.�4�in- Svrz/ Other Ph.
Phone ��`� ' `�� Other Ph. Contractor Reg. # ��u-�aqei7v2_Exp. "-^ 7""
Lien/Title Holder E Mail Address U3w tt�v-��1��'� "'"sJb orl
E mail address �� -- DOB �1 L(�
_,_ 3 Drivers Lic.# u �•tt��T t
Drivers Lic.# N�-iCA!Q i L,4' Z DOB i Existing Septic
SEPTIC /WATER SYSTEM INFORMATION - Connect to N��eptic 9
Connect to Water System Nameof Water System �, w
Well Sewer Syste Name of Sewer System
., .. Fire District
PARCEL INFORMAT ZON - Digit Rarcel N .
Legal Description
Site Address (Please include street name, street numb and city)
Directions to siteI}n�-
C.o-nTngvri
Will timber be cut and sold in parcel preparatiLake Yes/ o River/Creek Pond
Is property within 200' of Saltwater — Stream Slopes or Bluff 5%
Wetlande—Seasonal Runoff__
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action Add�Al S ASONAL
TYPE ❑
OF JOB - New t Repair Other__ PRIMARY RESIDENCE
Use of Building-6 Describe Work 2nd Floor
No. of Bedrooms No. of Bathrooms _Square Footage- 1st Floor S ft.
3rd Floor Basement Deck Covered Deck �r__�%- Other q
Carport Attached Detached --
Garage Attached Detached P
Model Year
MANUFACTURED HOME INFORMATION - Make No. of Bedrooms No. of Bathrooms
Length Width Serial h Replacement Unit? Yes/ No
Type of Heat Purchase Price $ Certification No.
Installer Name rther ult in a stop work order or permit revocation.
are
OWNER/BUILDER Acknowledges submission of inaccurate information may res
Acknowledgement of such is bysignaure below.to do the eworkas proposed in the application gladecpare that Ii have obtained the perm fission from all
that I am entitled to receive t permit holder or
the necessary parties. If permission
is renedr d from
permission from themtto apply for this pe m t and conducttthe work propos this ed. The owner lication or eor or
o the above
proposed in the applicatio , is agent on owners behallf,srepre represents
for review inform
i speoction�Th sdperm permit/application ong becomes Inull &�oid f work or f Mason uthor¢ed access tconst construction is
described property a
not commenced within 180 days or if construction.INACTIVITY OF THIS suspended
CATION OF 180 DAYS WILL INVALIDATE THE APPL CATION.K IS B
MEANS OFAPROGRESS INSPECTION. Date 5/ ►'±fqj,
X Owner/Owners Representative Contractor (indicate which one) Date
by:
FOR OFFICIAL USE BEYOND THIS POINT AcceptedOTE
DEPARTMENTAL REVIEW APPROVED DENIED n
Building Department
PlanningDe artment
Environmental Health Department
Fire Marshal FEES
Site Ins ection
Buildin Permit Fee EH Review Fee
Plan Review Fee
Plannin Review Fee
Plumbin & Base Fee Other
Mechanical & Base fee State Fee
Wood /Gas/ Pellet Stove Fee Pre-Paid at Submittal
Violation Fee TOTAL FEES
Valuation $
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360)427- 6 the web w.Irw 360 275-4 n67 - Elma (360) 482-5269
us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner t '�� �-� Company Name
"A'eu,,; Mailing Address 'i 3 Z S w-� �`
Mailing Address z City 6 - * J State `wit Zip Coded ►?✓
City State WA' Zip Code c Phone � b ;ot7/ Other Ph. -
Phone 3 � � ' "f�' I Other Ph. •- �.'
Lien/Title Holder Contractor Reg.# l,tt-1-iag�i'f zn�' Exp.
E Mail Address Ww tt e,ri�lr�c1� w�db, 01�q
E mail address I`-'G t"' DOB �13rJ! i
Drivers � Drivers Lic.# w�-c-i�c1��cS►-jS
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic_ _ Existing Septic
Connect to Water System Name of Water System—
Well— Sewer Syste Name of Sewer SystemFire District
PARCEL INFORMAT ON - 12 Digit rcel N
Legal Description
et numb and city)
Site Address (Please include street name, stre 3'�1 � f 6 crc 3
Directions to site 'a'tt-'' 1°"""
Sto
Will timber be cut and sold in parcel preparation. es/ o River Creek Pond
Is property within 200'of Saltwater �_
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_G Alt Repair Other PRIMARY RESIDENCE ® SEASONAL ❑
Use of Building -50 "" Describe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck_96, Other Sq. ft.
Attached Detached Carport Attached Detached
Garage Year
MANUFACTURED HOME INFORMATION - Make Model
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? Yes/ No
Certification No.
Installer Name
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 1 am the owner,ow cation.rs gladeclarre that I�have obtained the or the operm permission from all
that I am entitled to receive this permit and to do the work as proposed in the any in the necessary parties. If permission is required from any easement holder for other
and conducttthregarding
work proposed. The owner eor work
proposed in the application, I have obtained permission from them to apply p
agent on owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the above
described propertyed within 180 days or if constructio review and n work is suspenection.This ed for permit/application er od of 180 days.PIROOFIOF CONTINUATION OF WORK Id if work or authorized DS BY
not MEANS
MEANS OFA PROGRESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPUCATI
Date ►q fYlo
X Owner 1 Owners Representative Contractor (indicate which one)
Date
Accepted by:
FOR OFFICIAL USE BEYOND THIS POINT OTE F 9 '177
DEPARTMENTAL REVIEW APPROVED DENIED n
Building Department `s
Plannin i Department
Environmental Health„Department �
Fire Marshal FEES
Site Inspection
Buildi ig Permit Fee EH Review Fee `
Plan Review Fee
Plan iing Review Fee
Plumbinq & Base Fee Other
Mechanical & Base fee 11
State Fee
Wood/Gas/ Pellet Stove Fee Pre-Paid at Submittal
Violation Fee L7-- —
TOTAL FEES
Valuation $
PERMIT NO �` �, - ' ' 4
MASON COUNTY r
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-906n 0 eB web irw 360c 275-4 n67 * Elma (360) 482-5269
us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Company
Owner Name
��,,.: ' .- �
Mailing Address
Mailing Address`` -
State Zip Code
y State * Zip Code / f Phone' p
city - Other Ph.
Phone % ` �" f Other Ph. Contractor Reg. * Exp.
Lien/Title Holder E Mail Address
E mail address f A " DOB
Drivers Lic.# ,z. :� = .. �. r DOB "' =r'f
Drivers Lic.# ;, � � � �.-` '
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System Fire District
PARCEL INFORMATION - 12 Digit Parcel No.
Legal Description
Site Address (Please include street name, street number and city)
Directions to site
Will timber be cut and sold in parcel preparation?Yes/No, River/Creek Pond
Is property within 200' of Saltwater � ,/. Lake
Wetland—Seasonal Runoff Stream -` Slopes or Bluff— s S15%
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 0 SEASONAL ❑
. _
Use of Building ',� i �"''` Describe Work F_ :, 2nd Floor
No. of Bedrooms —
No. of Bathrooms Square Footage- 1 st Floor
Deck Covered Deck � „ '?"—Other Sq. ft.
3rd Floor Basement Attached Detached
Garage Attached Detached Carport
Model Year
MANUFACTURED HOME INFORMATION - Make No. of Bedrooms No. of Bathrooms
Length_Width—Serial No. Replacement Unit? Yes/ No
Type of Heat Purchase Price$
Certification No.
Installer Name
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit retractor. I vocation.
Acknowledgement orf such ecei el this sermituand to do theework aclare s proposed t I am the owner,he appiicat oln legal
declare that tI have obtained the permission the conf rdfromrall
that I am entitled to P in interest
the necessary partork
iei tionrrl have obtainedrpermiss on ed from from them easement
to apply foathis permit and conduct the work propoa this ece The owner olication or the ro the e
proposed in the app
agent on owners behalf, represents that the information provided is mit/apaccurate
licat ongrants
becomes mull &void f wok or f Mason a thor zedss tconst uction is
described property and structure for review and inspection. This permit/application
not commenced within 1 INSPECr if construction work is TION.INACTIVITY OF THIS PERMIT APPended for a LICATION OF days.eriod of 180 8 DAYS WILL INVALIDATE THE APPL CATION K IS BY
MEANS OF A PROGRESS
Date.
Owner I Owners Representative I Contractor: (indicate which one)
Accepted by: Date
FOR OFFICIAL USE BEYOND THIS POINT NOTES
DEPARTMENTAL REVIEW APPROVED D
�NIED
Building Department
Planning Department
Environmental Health Department
Fire Marshal FEES
Site Ins ection
Buildi ig Permit Fee
Plan Review Fee P ~� EH Review Fee
��-- Plan nin Review Fee
Plumbing & Base Fee Other
Mechanical & Base fee �-- State Fee S�
Wood/Gas/ Pellet Stove Fee
Pre-Paid at Submittal
Violation Fee TOTAL FEES
Valuation $
MASON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-96n 0 e web B irw 360)275- 467 - Elma (360) 482-5269
0
A CONTRACTOR INFORMATION
APPLICANT INFORMATION
Company Name
Owner Mailing Address
Mailing Addre
ss
City
State Zip Code
City
t ,.,.,�<, , �
State � Zip Code Phone
Phone Other Ph. r " Other Ph.
fE=%�- —
Contractor Reg. # Exp.
Lien/Title Holder E Mail Address
E mail address r,, " DOB
Drivers Lic.# •z' ` a' t%'' DOB
} ;,) Drivers Lic.#
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Sewer System Name of Sewer Syste Fire District
PARCEL INFORMATION - 12 Digit Parcel No.
Legal Description
Site Address (Please include street name, street number and city)
Directions to site
Will timber be cut and sold in parcel preparation? es/No ' River/ Creek Pond
Is property within 200' of Saltwater " ' ' Stream_ Slopes or Bluffs 15%
Wetland Seasonal Runoff
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 E] SEASONAL ❑
...
Use of Building _ —__. —-_-----Describe Work 2nd Floor
No. of Bathrooms _—Square Footage- 1 t Floor
No. of Bedrooms__No. Deck—Covered Deck_.=—Other Sq. ft.
3rd Floor Basement Attached Detached
Attached —Detached Carport------
Garage -- Model Year
MANUFACTURED HOME INFORMATION - Make No of Bedrooms No. of Bathrooms
Length Width Serial No.
Purchase Price $ Replacement Unit? Yes/ No
Type of Heat Certification No.
Installer Name
ult in a stop work order or permit revocation.
OWNER/BUILDER Acknowledges submission of inaccurate information may res ers legal
Acknowledgement of such is by signature below theework as proposed he t I am the owner,
declare that II have obtained the permissionf rdfrom all
that I am entitled to receive this permit and to d in intere
the necessary parties. if
permission II have obtained permission permiss on f from themeasementto apply for this permit and conduct thework regarding this
The owner cation or the
or
proposed in the application is accurate and
ve
agent on owners behalf, represents
for that
rey theiew information
rmainstio tion�Tdh sdperm applicatio grants becomes employees
& �oid f work or af Mason uthor zed access tLonst u the bt on is
described property and structure
not commenced within 180 days or if N.INACTIVITY OF THIS PERMIT APPLICATION OFd180 DAYS WILL INVALIDATE THEAPPL CATION.IS BY
MEANS OFAPROGRESS INSPECTION.INAC
,,..._ Date:
X Owner/Owners Representative t Contractor (indicate which one)
Accepted by: Date
FOR OFFICIAL USE BEYOND THIS POINT NOTES
DEPARTMENTAL REVIEW APPROVED DENIED
Building Department
Planning Department _U
Environmental Health Department
Fire Marshal FEES
Site Ins ection
Buildin Permit Fee EH Review Fee
Plan Review Fee
Plannin Review Fee
Plumbin & Base Fee Other
Mechanical & Base fee State Fee
Wood /Gas/ Pellet Stove Fee Pre-Paid at Submittal
Violation Fee TOTAL FEES
Valuation $ __
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TOPOGRAPHY PROFILE: Y MASON tOUN 1`?' DCD PUNNING
SITE PLAN REQUIRED TO BE ON SITE
CHANGES SUBJECT TO APPROVAL
By M" Date
—7 Direc' n: Scale: Approval: for office use
Building Permit number: 04 — IZ71 / Building:
Owner/Applicant:
17r, C_ Date of Planning:.
application: Env. Health:
Parcel Number:
MASON COUNTY DEPARTMENT OFl�i�IMUNITY DEVELOPMENT
WSEC/VIAQ Compliance Application
Owners Lv_ ��7 r Telephone:(34110) r/ Parcel#: f
Type of project ( ) New Residence ( , Addition ( ) Remodel
Total Sq. Ft. 1 s Floor: 2" floor: Heated Basement:
of heated area::
Heating System Type: *Electric wall heater O Electric Central Furnace O LPG Furnace
O Heat Pump with electric furnace O Heat pump with gas furnace O Boiler, specify fuel type:
O Other: Specify
Glazing O Prescriptive Option see reverse side circle one: 1 II IV
Percentage: Compliance
Method O Component Performance , Chapter 5— Calculation worksheets required
Check one:: O Systems analysis, Chapter 4
Whole House Ventilation system O Whole House Ventilation using a Heat
Ventilation using exhaust fans&window or wall fresh air Recovery Ventilation System (VIAQ 303.4.4)
System vents (VIAQ 303.4.1
Check one
O Whole House Ventilation Integrated O Whole House Ventilation using an inline
with a Forced Air System (VIAQ 303.4.2) supply fan. VIAQ 303.4.3)
Window & Door Schedule (If needed, attach an additional sheet)
Total
Manufacturer Room/location U-Factor Size Quantity Square Feet
Windows:
Windows: Total Sq. ft. 4 Sq- i T,
Doors:
Doors: Total Sq. Ft
Total window and door area 54; ,
Total window &door area /(divided by)total sq.ft of heated area = %of glazing
Mason County Permit Assistance Center
Planning Intake Checklist
Owners Name: Date:
Project: S Reviewed By: C,
Commercial Development:' YM 7&(51 Comments:
Planner: GBM TSC CMM PBCO
Site Plan:
North Arrow
W-Troperty Dimensions: X_ _
e'Streets and Driveways Shod name: tuldl
p-'*"'All Existing Structures shown with setbacks
o Webb , Septic and Drain-field Shown with setbacks
o Nefifif surface water(streams,ponds,shoreline,wetlands,etc.)
o T"pegmpfry(slopes)
p-'Proposed StrucTe Setbacks(Dir tion/Setback):
F: r / 'T R: / S 1:9/l S2:
gyp' Utility and Drainage Easements: Yes Nc (if yes enter condition#5022)
w"OtherEasements /'1Q(�
Accessory Appurtenances )'1prU—
t ed(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
Are there any i mpeed�iments that may restrict access to your site? (dogstgates)
Shoreline and Planning Info
Setbacks:Shoreline: Slope:
Shoreline Designation: Comprehensive Plan: Rural Zoning:
❑ Not Applicable 0 Agricultural 0 RR 2.5 5 10 20
0 Urban ❑ In-holding 0 RMF
0 Rural 0 LTCFL 0 RC 1 2 3
❑ Conservancy 0 Rural 0 RI
0 Natural ❑ RAC 0 RNR
❑ Unknown 0 RCC-Hamlet 0 RT y�
$a-Urban.Growth Area 0 MPR K t T
0 Unknown . 0 Unknown
Water Body(type of water if unnamed): M (\-a--
SEPA: Yes 6 Unknown
Flood Plain: YES N Unkno Ma #
Aquifer Recharge: YES N Unkno Map#
Tags/Cases:
RLC/SPI Case: 10 O ty 6-Year Dev.Moratorium: YES
Eagle Nest Tag: YES NO Other YES
Addressing: Check box if needed 0 Reviewed by:
Revised: I1-01-2005 I:\PL.ANNMG\PAC\PLANNING INTAKE
1