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BLD2008-00093 Replace SFR - BLD Permit / Conditions - 1/24/2008
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NOJbIU `�)11�-000g3 PLEASE PRESS HARD BUILDING W. Cedar Po MI Box 6APPoLI CATION �t oj 8584 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 1*21#1 u- S. 6?W7, Company Name JO JNE.e Mailing Address a741 At, Mailing Address City 221C.02,40 State WA Zip Code 9"NO-Z City State Zip Code Phone2S'3•?L/-Z'S•oo Other Ph.=_3-_VO-SZL/ Phone Mo Other Ph. Lien/Title Holder s!SVIE Contractor Reg. *L Exp. E mail address 8 S/rl/Ti/2 SIB?/Ti�1�i/2E.C'.q1 E Mail Address Drivers Lic. DOB l- SZ Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Sewer Systern X Name of Sewer System- 4:;�/ PARCEL INFORMATION - 12 Digit Parcel No. /P-2SJ W66OZIO Fire District Legal Description iMIZE/¢TTACA&MD Site Address (Please include street name, street number and city) 422 ems. Sa 3-02 wg " Directions to site 3 7V --se— 302-'RA' 6Z. a EAST TW &«''00.T7- S'-, 'Oe/i"T s//1g_ <GTO Will timber be cut and sold in parcel preparation?Yes/ Is property within 200'of Saltwater X Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New C Add Alt Repair Other PRIMARY RE,$IDF-NCE ® SPASQNAL ❑ Use of Building RF-51,0"CE' Describe Work MEW ��T�G�/� -��� a{ QL�_ No. of Bedrooms___-3 No. of Bathrooms Square Footage- 1st Floor 2lo8ry 2nd Floor 3rd Flo Basement Z&% 2 Deck Covered Deck Other Sq. ft. arag e'd -208 Detached d _ 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 OFAP GRESS I SP CTION.1 CTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. X Date: caner/Own epresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by dintj Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department iG ! Oo1o5 Environmental Health Department Fire Marshal FEES Building Permit Fee Site Ins ection Plan Review Fee EH Review Fee Plumbing & Base Fee Plannin Review Fee Mechanical & Base fee Other Wood /Gas/ Pellet Stove Fee State Fee Violation Fe I Pre-Paid at Submittal Valuation $ TOTAL FEES MA O Q UNTY PERMIT NO.�; BUILDING PAR APPLICATION -- 426 W. Cedar• P.O. BeA186, Shelton, WA98584 ................... l _.1 Shelton (360) 427-9670 • Belfair (360) 275-4467 - Elma (360) 482-5269 1 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner /`� k' w�f'J!l Company Name 044JAle'A. Mailing Address 4;7Z I Al, " -2/M"E' 4,'y/ Mailing Address City-2 4? State W4—Zip Code ' - I'"' C statit Zip Code Phone2-'r3•'%C/-Zd'd0 Other Ph.Zff- 0 - / Phone 5,pt9 Other Ph. Lien/Title Holder -"-ry*14AF Contractor Reg. # Exp. E mail address 46 -5NII'N'4i / y /°4 • C1#1 E Mail Address Drivers Lic.# nn DOB /-4r-- Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Sewer SystettL2!�-- Name of S er System !!;;�qt/el/?"� PARCEL INFORMATION - 12 Digit Parcel s. f aZ Fire District Legal Description —"Se Site Address (Please include street am -, street number and city) •42 2 0 Ar. 3C Z 40C1 /oc A Directions to site •` ' �` '` ✓df+rT ass / TJ Will timb put and sold in parcel preparation?Yas/ ` Is props Within 200'of Saltwater �—Lake • River/.-Croek Pond Wetlanj,4 Seasonal Runoff Stream Slopes or Bluffs > 15% Is thispermit submittal the result of a Stop Work Notice,Correction Notice,or other enforcement action?Ye§/No' TYPF,, OF JOB - New_,X Add Alt Repair Other PRIMAR RE�IDENCE ® S�ASONAL E:]Use of"Building oVe511.4WC.& Describe Work WAFW �� �-��'�� o No. of Bedrooms--3 No. of Bathrooms 4*0 _Square Footage- 1st Floo 2nd Floor 3rd FlooC BasemerILS-4-24- Deck vdred Deck Other Sq. ft. crag `t2v£3 Detached Carport - ' Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length"—Width Serial No. No. of Bedrooms No. of Bathrooms Type f`Aeat Purchase Price$ -�27 ' Replacement Unit? Yes/ No InQ;Mler Name Certification No. OW ER/BUILDE "cRnowledges 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 necesry parties. If permission is required from any easement holder or any other party in interest regarding this application or the work proposed m the application, I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or i 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 foo{{review and inspection. This perm it/appIication becomes null & void if work or authorized construction is not commencda within 180 days orif construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OFAPPOGkESS IN SP CT ON.IISACTIVITYOF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: ` .� wner/Own epresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by:!I-,, ra Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department r` Planning Department P11 � ;r� t: 1 t`�{')Environmental Health Department Fire Marshal FEES Building Permit Fee Z 7 Z Site Ins ection Plan Review Fee EH Review Fee Plumbing & Base Fee Planninq Review Fee Mechanical & Base fee 33 2✓ Other Wood/Gas/ Pellet Stove Fee State Fee Violation Fee F' Pre-Paid at Submittal Valuation $ j 2 6. l TOTAL FEES FORM MUST BE COMPLETED IN(NK MAy QN,COUNTY PERMIT NO16IU�-�q� PLEASE PRESS HARD 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 INFORMATION CONTRACTOR INFORMATION Owner 11AAA" A!5• Company Name QLJ,NE� Mailing Address G?2/ Al, A,Pk�iD�'Gt/ Mailing Address City���s4 State WA Zip Code 9'69D? City Stat Zip Code Phone2S3-?L/-2S'oo Other Ph.213-MO-SZZ/ Phone Other Ph. Lien/Title Holder -�jg Contractor Reg.# Exp. E mail address SAYIjryf 2 S/K/ C"f E Mail Address Drivers Lic.#S21 !W DOB Jf- SZ Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Sewer Systern.X,_ Name of Sewer System * PARCEL INFORMATION - 12 Digit Parcel No. /Z2Z GId024 Fire District Legal Descriptions ArT/1►��l,��� Site Address(Please include street name, street number and city) 4220 vim. 3aZ ,Qlr'l�;�st2,ZM14 ' Direction to site 3 72 '%C g02.RA- 6 T. igO AWS777 TQ 4ErQ9 _ AOV V/6Jr4950, Will timber be cut and sold in parcel preparation?Yes. Is property within 200'of Saltwater X _Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New_2!5_Add Alt Repair Other PRIMARY REjID6NCE ® SEiASQNAL ❑ Use of Building R"Vt�✓E Describe Work ��1+A/ �sreu�Ts�y ,GmO d O No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor 2ro81k 2nd Floor 3rd Flo Basement Za32. Deck Covered Deck Other Sq. ft. arag wed /fig' , Detached t _ _ Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Type of Heat Purchase Price$ lreff 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 owln_ers 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 hull &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 WOGRESS 1 SP CTION.I CTIVITYOF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X Date: wner/Own epresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by:4UMU Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department ._ iG l - Oa05 Environmental Health Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing &Base Fee Planning Review Fee Mechanical& Base fee Other L /Gas/ Pellet Stove Fee State Fee ion Fee Pre-Paid at Submittal tion $ TOTAL FEES MASON 40UNTY PERMIT NO. t •G1�0�;3 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 - 1 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner �ti f f F Company Name 0 <:, AJe',' Mailing Address »- •€� `' �� ,t; " Mailing Address City _Statell2t Zip Code Citr- Stat Zip Code Phone �` Other Ph.d ` •'=a w ./ Phone / '' Other Ph. Lien/Title Holder Contractor Reg.# Exp. E mail address '# `' f'`'° " '` `` '' E Mail Address Drivers Lic.# a'1122jl�L0 DOB I-ZS0-:;E,2 Drivers Lic.# DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Sewer SystenL2�_ Name of Sekver System- N ,; `� ` ` ' r"�,� � PARCEL INFORMATION - 12 Digit Parcel l' 4.5 032 Fire District Legal Description » y Site Address(Please include street name street number and city) 42*WO -» i i< 'x a �- ,r , w3' J"1 '•.�+ r xt' p Directions to site o4p 1,K� �'._ , Will timber by cut and sold in parcel preparation?Yes/ Is property,within 200'of Saltwater A _Lake River/.Creek Pond WetlanO 1' 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 X Add Alt Repair Other PRIMARY RESIDENCE ?9.A SEASONAL ❑ Use of'Bpilding 'o'"�/l?J VC'.' Describe Work .�'�r'EA- ' �.,. No. of Bedrooms__ -3 No. of Bathrooms 4 Square Footage- 1st Floor 2nd Floor 3rd_Floor 6 Basement 0 14 Deck Covered Deck Other Sq. ft. arag 7` "A#eehed ZCe DetachedN — Carport ' Attached Detached MANUFACTURED HOME INFORMATION - Make ' Model Year Length Width Serial No. ,s ' No. of Bedrooms No. of Bathrooms Typepf Heat Purchase Price$ Replacement Unit? Yes/ No Installer Name Certification No. OWNER/BUILDER"AcRnowledges 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 OFAPPPGRESS INSPECTION*INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. X ;� .r Date: ''Owner/Owne epresentative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by:''» " DateM` f 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 Planning Review Fee Mechanical & Base fee Other Wood/Gas/ Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES FORM MUST BE COMPLETED IN INK PERMIT NO.W 2M� �J PLEASE PRESS HARD MASON COUNTY PLUM BING/MECHANICAL PERMIT APPLICATION 426 W.Cedar•P.O.Box 186, Shelton,WA 98584 Shelton (360)427- 7t% Be' (360)275-4467•Elma(360)482-5269 n t e webb www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner 4I B• SkiTi1 Company Name Mailing Address i 7Z/ M PA.VA-:5LQE LN Mailing Address City ';Me-omw state ,G!,* Zip Code_28407 City t Zip Code Phone 2S*3'?61-ZSoo Other Ph,4&-.?Agv'SZZI Phone Other Ph. Lien/Title Holder DwAOfAffiQ Contractor Reg. Exp. E mail address .6SW2MM SvK/Zs�Fi.CE�.«'�N E Mail Address Drivers Lic.# DOB /—ZT-S2 Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic. Connect to Sewer System x Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel No. /ZZz/ 4 OZO Fire District S Legal Description ZWOE F� Site Address (Please include street name, street number and city) -OZZO 4E 50S 307— . ASLAWAe. g Directions to site H`✓y 3 TD 30Z �.9�T aD 6 A57 ?h �llGE'.OAST J7- Is property within 200'of Saltwater X Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% TYPE OF JOB - New_K_Add Alt Repair Other Use of Building Location of Fixtures/Units- 1 st Floor Z& 2nd Floor. Basement_ Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electriq LPCz2L Natural Gas__ Heat Pump_ Toilets jype of Unit No.of Units Fees Bathroom Sink Furnace 2 Bath Tubs Heatpumps 2 Showers Spot Vent Fan Water Heater Propane Tank Clothes Washer Gas Outlets 1•I5 _�.'15 Kithen Sinks 2 Wood/Gas/PelletStove Dishwasher Kitchen Exhaust Hood / Hosebibs 4 Dryer Vent Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OWNER/BUILDER Admowledges 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 holier or any other party in interest regarding this application or the work proposed in the application,I have obtained I 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 a ees of Mason County access to the above described property and structure for review and inspection. PROOF OF CO N O ORK BY MEANS OF A PROGRESS INSPECTION. X Date: �-t7 ner/own presentative/Contractor (indicate which one) FOR OFFICIAL USE BEY N HI POINT Accepted b . Planning Pd Ck# Date Bld Pd Receipt No. DEPARTM TAL REVIEW APPROVED DENIED NOTES Building Dep ent Occ Grou T e Constr. PlanningDepartment Environmental Health Department FEES Plumbing &Base Fee Site Inspection Lnical &Base fee UFC Plan Review Fee /Gas/Pellet Stove FeeOther on Fee TOTAL FEES PERMIT NO.Y;,,d,�l2(2 MASON'C tUNTY PLUMBING/MECHANICAL ERMIT APPLICATION 426 W.Cedar•P.O. Box 186, helton,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. 4,#ze 9. SflrW Company Name Mailing Address NOS / Al .0&1G0k"s1©A' L.y Mailing Address City 22 e-Q&,&---State Zip Code,?'-12Z City t Zip Code Phone 253-?`�/-ZSao Other S?Z/ Phone Other Ph. Lien/Title Holder Contractor Reg. Exp. E mail address �65�7�T�/G: S�!'rrNr�.e cc E Mail Address Drivers Lic.# DOB /-ZS-S2 Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System x Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. /ZZ Z/ 49 D oz to Fire District Legal Description Site Address (Please include street name, street number and city) 42ZO 4f, Z R 30Z o6 /A, �4 Directions to site�V 3 7-D --A 90Z �sZ; 6© 4046r 7b &Zge GLS T S- SC ek'/6Wr Is property within 200'of Saltwater X Lake River/Creek Pond Wetland Seasonal Runoff—Stream—Slopes or Bluffs > 15% j TYPE OF JOB - Newer Add Alt Repair Other Use of Building Location of Fixtures/Units - 1st FloorlG2_ 2nd Floor Basement_ Garage Closet j PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electric LPCz& Natural Gam_ Heat Pump_ Toilets 4 _ Type of Unit No. of Units Fees Bathroom Sink ,:s" Furnace Bath Tubs / Heatpumps 2 Showers 3 Spot Vent Fan 7 Water Heater Propane Tank ' Clothes Washer 1 Gas Outlets 1. 15 - Kithen Sinks WoPellet Stove i � Dishwasher Kitchen Exhaust Hood Hosebibs �— �r��" Dryer Vent fj,�c Z Base Fee Base Fee 41 4 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 fl provided is accurate and grants a loyees of Mason County access to the above described property and structure for review and inspection. PROOF OF CO IN INATI O ORK I BY MEANS OF A PROGRESS INSPECTION. X Date: 2�- ner/Owner presentative/Contractor (indicate which one) I I FOR OFFICIAL USE BEY N HI POINT by C Accepted Planning Pd Ck# Date - Bld Pd Receipt No. DEPARTM TAL REVIEW APPROVED DENIED NOTES Building Depek�t ent kOcc GroUD-Type Constr. Planning Department Environmental Health Department I. FEES Plumbinq &Base Fee Site Ins ection I{ Mechanical & Base fee UFC Plan Review Fee { Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES PERMIT NO.( MASON C IJNTY PLUMBING/MECHANICAL ERMIT APPLICATION 426 W.Cedar-P.O.Box 186, helton,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 I FORMA Owner, J�I!/,C,& 4F. c!i/0/`7-A✓ Comp an Name Mailing Address,467'Z/ Al /�'/1�Xie6ID-E QV Mailing Address City *�M C-L"A State kl,* Zip Code Y GIT City Zip Code Phone ZS 3-7.6/'L St Other PhZ.5.,,'-.76G•-TZd 1 Phone Other Ph. Lien/Title Holder 4QkVNjMk Contractor Reg. Exp. E mail address 0SI//12G: / ' / J` E Mail Address Drivers Lic.# DOB J��'.�5-Ss. Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System X Name of Sewer System 7 PARCEL INFORMATION- 12 Digit Parcel No. /Z2 Z 0 Fire District Legal Description 4 +rA Site Address (Please include street name, street number and city) Directions to site / -'©4 A S7 Q 0,,#ST ?"b '�#'!L���7 'S S, 41�/6 6V r 1Af/ V'/G,r Is property within 200'of Saltwater X Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% TYPE OF JOB - New N Add Alt Repair Other Use of Building f Location of Fixtures/Units- 1 st Floor '� 2nd Floor Basement t Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS ype of Fixture No. of Fixtures Fees Fuel Type:Electric L P G—K Natural Gas_ Heat Pump_ Toilets _4 Type of Unit No.o_ f�s Fees Bathroom Sink SM Furnace Heat um s z Showers s Spot Vent Water Heater Propane Tank Clothes Washer Gas Outlets 1.15 •r Kithen Sinks 2 Wood/Gas/PelletStove Dishwasher a — Kitchen Exhaust Hood Hosebibs 4 Dryer Vent T ,+-/"t.F.�""C/A/'tz6 z Base Fee Base Fee 4& A 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 l 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 a loyees of Mason County access to the above described property and structure for review and inspection. PROOF OF CO NI)ATI O ORK I BY MEANS OF A PROGRESS INSPECTION. X ./ r Date: A ner/Own>96presentative/Contractor (indicate which one) { FOR OFFICIAL USE BEY N H! ,POINT Accepted by Planning Pd Ck# Date T � U � —Bid Pd Receipt No. DEPARTME TAL REVIEW APPROVED DENIED NOTES Building Depart ent Occ Grour)—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 PERMIT NO. a MASON COUNTY PLUMBING/MECHANICAL ?ERMIT 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 a -- t 1 Company Namea-•`.:' . Mailing Address''Z', Mailing Address City,. State t Zip Code -4--:4 Z City to -- Zip Code Phone �� Other Ph. fi ": , Phone °' Other Ph. Lien/Title Holder Contractor Reg. Exp. E mail address E Mail Address Drivers Lic.#-. ti DOB Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic. Connect to Sewer System Name of Sewer System ' ' '* "" PARCEL INFORMATION- 12 D! Fire District Legal Description "' 41" d Site Address (Please include street name, street number and city)'=-" 7 `0 a 6L42, Directions to site Z21 A, r Is property wiflhin 200'of Saltwater X 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- list Floor-.L�- 2nd Floor Basement g!j' Garage Closet PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electric LPG X Natural Gas_ Heat Pump_ Toilets Ali Type of Unit No. of Units Fees Bathroom Sink --=4= Furnace ? Bath Tubs Heatpumps s: Showers Spot Vent Fan Water Heater > Propane Tank f Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PelletStove t Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent d 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 1 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 a loyees of Mason County access to the above described property and structure for review and inspection. PROOF OF CONTINUATION OF ORK I BY MEANS OF A PROGRESS INSPECTION. X '. rf Date: L t ner/CSwner presentative rbontractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted byres_Planning Pd Ck# Date Bid Pd Receipt No. li DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Group----�Type Constr. Planning Department Environmental Health Department FEES Plumbing& Base Fee Site Ins ection Mechanical & Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES THIS PARCEL INCLUDES PLANS, BLUEPRINTS OR, OVERSIZE IMAGES LARGE FORMAT IMAGES HAVE BEEN STORED IN FILE CABINETS) UNDER PARCEL NUMBER PARCEL # /aaa i - �_ - 000aD /4� SE #&/J 20DR- OOVJ3 rna � Mason County Permit Assistance Center Planning Intake Checklist Owner ame: Date: �-2�1-Q8 Projec Reviewed By: Commercia Development: YES mments: Planner: GBM TSC KJM PBC RDH JMS Site Plan: � �-e�G A ,1,0__�orth Arrow - Property Dimensions: I CC X �-6 Streets and Driveways Shown. Road name: S" e_+ 2)02- X15 tructures shown with setbacks ❑ el Locatio eptic and Drain-field Shown with setbacks en ' surface water(streams, ponds, shoreline, wetlands, etc.) Topography(slopes) : � 5 4L LU 95+ Proposed Structure Setbalslks(Direction/Setback): I F: J4a l E' R: (06 / O S 1: 10 S2: Utility and Drainage Easements: Yes No (if yes enter condition#5022) Appr�UQ�I Other Easements Accessory Appurtenances TAn V , L.P6, P, hjr,+ IP V 7 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 Are there any impediments that may restrict access to your site? (dogs/gates) no Shoreline and Planning Info Setbacks: Shoreline: Slope: Shoreline Designation: Comprehensive Plan: Rural Zomn ❑ Not Applicable ❑ Agricultural RR 2.55 10 20 X Urban ❑ In-holding ❑ RMF ❑ Rural ❑ LTCFL ❑ RC 1 2 3 ❑ Conservancy Rural ❑ RI ❑ Natural ❑ RAC ❑ RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT ❑ Urban Growth Area ❑ MPR ❑ Unknown ❑ Unknown Water Body(type unnamed): C . n M1, SEPA: Yes o Unkno Flood Plain: YES N nkno Map# Aquifer Recharge: YES N Unkno Map# Tags/Cases: RLC/SPI Case: bOD-p S 6-Year Dev. Moratorium: YES Eagle Nest Tag: YES 80V Other YES N Addressing: Check box if needed ❑ reviewed b�- Revised:12-19-2007 I:\PLANNING\PAC\PLANNING INTAKE 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 1. Complete Part 1' No deterininefion can be made until Parfi`1 is full}tnt[ated. 2. Ccxrrt [ete drily the portitan Of Part,2 applying to the t c f w fersy i�uttlt d: M li a:" l'i film,wild attacllt ent fox ifear review. PART 1: Applicant/Parcel Identification Name of Applicant Af� 8 6SVI71'61 Date Mailing Address 67ZpN 4o/ Telephone Z5Z-76/-2�'00 Assessor's Parcel Number /ZZZ/ -03 Ar.)OZO Type of Water System Check One):. Reason for Application Check One): ❑ Public/Community Water System(2 or more Building permit connections)" ❑ Land use application, if so.. Individual water source(one connection), ❑ Division of land: if so.. 4pEnnagD/surface #of Parcels?—_—_ SPL____-____ water ❑ Boundary line adjustment ❑ Other(explain)--_—�-- ❑ Other(explain)----_ **If you have more than one residence Replacement(please indicate name of water system connected to this well, check the Public box. beloylif applicable—no signature required) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water System Name of Water System Water Facility Inventory(WFI) Number: (write"none"for two party) ❑ I am the manager of this water system.The wat stem has been approved for services. There are presently connections se.This will be the connection. ❑ I am the manager of this syste is connection will be to upgrade or change the use of an existing connection on thi tern(ie:recreational to full time). Please indicate on the following line the nature of this ge: This water s m is able and willing to provide water to this(these)connection(s)without exceedi e limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date Update:April 2006 Individual Water Well Water well report(attach to application) Depth 5_1 -_ft. Well capacity test(attach to application) ---/49 _gpm 23 D4d gpd e well dfiller often performs well capacity tests at the time the well is constructed. Results from these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test,a well capacity test, which provides stabilization of draw-down and recovery data must be Performed by a licensed contractor. Satisfactory bacteriological test(attach to application) Individual S rin /Surface Water WDOE permit (attach to application) Method of disinfection ❑ 1 have reason to believe that this water source n p e avP6 t least 800 gallons per day and/or provides water at a rate of 2 gallons per minute ed on the following observations. AUTHOR OF STATEMEN _ ---DATE-_--___ RELATIONSHIP TZROVIDING - - - - _ IN ADDITION TO THE ABOVE STATEMENT,THE APPLICANT WILL NEED TO ARRANGE AN ON-SITE INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY. Departmental use only. Do not write below this line. PART 3 Health eipartmerd Evaluation (Staff tlsd Only) SATISFACTORY DETERNIINATI,ON: Applicant's water supply appears adequate to meet the needs cif Its:intended use. This detertninatbh d fr e ,n f address adequacy of the distribution system,guarantee an adequate sulzply f water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regulations. UNSATISFACTORY DETERMINATION:Applicant's water supply does not appear adequate to-meet the needs of its intended use for the following reason (s): REVIEWER'S SIGNATURE DATE Update:April2006 1 Name Parcel# /ZZZ 43 9WOZO 13LD# Mason County Department of Community Development Small Parcel.Stormwater Management Application/Worksheet (page 1 of 2) Per Mason County Code,Title 14, Chapter 14.48 a stormwater site plan is required-whenever a building application is made for residential development,or redevelopment',with more than 2,000 square feet of impervious surface . 'Redevelopment means,on an already developed site, the creation or addition of impervious surfaces,structural development including construction,installation or expansion of a building or.other structure,and/or replacement of impervious surface that is not part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment.. 2Common impervious surfaces include,but are not limited to,rooftops,walkways,patios,driveways,parking lots or storage areas, concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces. ;;.roti:t•,.'c %iry:.:•:,t"y.' " `:•:?k {. �r':•o; Y+yt,.,ciyyr�..;; :::..y?..:v::. ^ ��. : ..F.n7:F .nt:.vrf.+:v.+;iin'+r::G•.vY.+F.S.:^: ti^. Surface Type Length X Width = Area " All dimensions in feet Buildings X, _ X = Measurements for buildings are taken at the X perimeter of the farthest projections(example: eaves/gutters) X = Drivewa ys X = X BE K PT IN TNE Length of drive begins at the right of way X Parking Areas X _ X A,y paved,gravel or packed area per definition X _ above table Patios/Walks X = X Any paved,gravel or packed area per definition — above.table X Others X X — i4 X = If the Total Impervious.Surface Area is LESS THAN 2000 Square Feet,please read,acknowledge and sign below. Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity. Owner/Builder/Agent Acknowledges that 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,owner's legal representative,or the contractor.I further acknowledge that the information provided is accurate.and employees of Mason County are granted access to the above-. described property for re yew and inspection as may be required. X caner gent/ ontractor circle one)Date: If the Total I p rvious Surface Area is GREATER THAN 2000 Square Feet, please read, acknowledge and sign the information provided on page.2 of 2. ;( Page 1 of 2 f Names/_ r /mil Parcel# /ZZ7-1 43 OBOZO BLD# Mason County Department of Community Development Small Parcel Stormwater Management Application/Worksheet (page 2 of 2) Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity. Title 14,Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater Management in this jurisdiction. A complete copy of the ordinance can be found on the Mason County website: httn//www.co.mason wa—us/code/commissioners/indexhtm Please follow the links to "Title 14, Chapter 14.48 Stormwater Management". Regulated activities shall be conducted only after Mason County Public Works approves a stormwater site plan (Mason County Code Title 14 Chapter 14.48 section 14.48.70).You will receive a copy of the Public Works document entitled "Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan".This document will assist you in preparing the necessary information and plans for Public Works to review and approve. Per Department of Public Works this document will constitute an approved plan if all of the relevant details* are to be installed.in their entirety AND no part of the stormwater system adversely affects any septic system (see Environmental Health information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval. A design by a registered professional maybe required for more complex sites. *These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan on the pages that begin with"Handout" PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT P FOR THIS SITE „T .; A),The relevant details from Managing Storm Drainage oh Small Lots, The&Tall Parael Stormwater Site Plan will be installed in their entirety AND the system will be located as not to adversely4 t-'ny ep c,�syystems oil this,or any other,parcel: B) An alternative plan and/or professional design will be subiiiitteci to the Department of Public Works for approval AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel. If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works Department can provide additional instructions,guidance and examples. (Section 14.48.130)contact Public works at: Phone: (360)-427-9670 EXT.450 Mail:P 0 Box 1850, Shelton WA 98584 Physical: 415N 6th St, Shelton WA 98584 If this development has, or will have,a septic/drainfield system you may need to contact Mason County Division.of Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or any other,parcel.You may also wish to consult with the septic design professional involved with the project. Mason County Division of Environmental Health can be reached at: Phone: (360)-427-9670 EXT. 352 Mail:P 0 Box 1666,Shelton WA 98584 Physical: 426 W Cedar St,Shelton WA 98584 A condition will be added to the building permit that states,.in part,that all conditions the stormwater site plan will be met prior to a request for final inspection of the building permit. Owner/Builder/Agent Acknowledges that 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,owner's legal representative,or the.contractor.I further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- described property for re `ew and inspection as may be required. 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