HomeMy WebLinkAboutBLD2000-01056 - BLD Water Adequacy - 8/28/2000 1/ Jc p -,61b56
PERMIT NO.: BLD
MASON COUNTY
` BUILDING PERMIT APPLICATION gl�ty
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467.Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION ry tr r CONTRACTOR INFORMATION
+'Owner gin' <. q t I Contractor Name
Mailiog Address 0 AJ Mailing Address
City ; a State Zip Code —1 . City State Zip Code
Phone 6 a r�OtherPh.( Ph.( Ot4er Ph.(
Lien/Title Holder Contractor Reg. #
Address Expiration J
`SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System Name of Sewer System Well—,,Y_Water System Name of
Water System r
Gl O
PARCEL INFORMATION-12 digit Tax Parcel No. p Fire District -`
Legal Description T t'
Site Address(Please include street nafrw, street number a city)
Directions to site V_ <l /p 4, f -
Will timb r be cut and soldJn parcel preparation? (Yes/No)
Is your property within 200'of the following: Body of Water (Ngmb) kok 0 CO%4 '• �� �✓ Saltwater
Lake River/.Creek Pond Wetland Seasonal Runoff___Stream Slo es or
Bluffs "x
PERMANENT RESIDENCE❑ SEASONAL RESIDENOE14
TYPE OF JOB New Add Alt Repair Other Use ofButldil?,9
ti r
Describe Work
No. of Bedrooms. No. of Bathrooms ° SQUARE FOOTAGE71st Floor 2nd Floor
3rd Floor "Loft # Basement' Deck Other sq. ft.
Garage AttaOgd` Detached Carport Attauhed Detached
MOBILE HOME INFORMAT1104-Make/Vc4 V ," !..Model r t , � . to Model Year -0 0
Length „ '& Width i t %erial No. ,0 No. of Bedrooms `2� No. of Bathrooms
Type of Heat F"t.lrchase Price ,, ,C ,�. , _tom. Replacement Unit ?(Yes/No) )A n
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID.IF WORK OR CONSTRUCTION-AUTHOR12ED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above`described property and structures for review and
inspection of this`project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as p
Contractor Registration Law RCW 18.27 and am aware of the ordinance "":'contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
c
X Date " X Date r
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
... l F?;PXRTMENTPrI...E�IwV i�f PPRQVEU D I DE.
...........
I~..
..... .. ....... NRITlf D+ 17
Building Departmenta.iF, -r - # P C ,
Occ Group , Type Constr.
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
Valuation $
20.
IEE77777
RE
Building Permit Fee _.. Site Inspection
Plan Review Fee EH Review Fee
PlumbingA Basefee '`` Planning Review Fee
Mechanical&Base Fee Qther
Wood/Gas/Pellet Stove Fee State Fe?
Violation Fee Pre-Paid at Submittal
. ..::. ....Y. TOTAL FEES
MASON COUNTY PROJECT SITE INFORMATION
Case No.
Name s kt.-, ` PARCEL NUMBER-� i,o cy ;y Date {�
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography rAl
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
Names of Fronting Streets Septic System
1 a 0 J !
f on
DRAW SITE PLAN BELOW In ge adjacentproperties4 shoreline or within 100 feet of adjacent property line.
adjacent property lined I ,� t , I Fadjacent property line
Of I
I I
J
I
I '1
N.
I
"
I
I • � I
I I
adjacent prOpert line4 I t I Fadjacent property line
SAMPLE SITE PLAN � � `
adja t property line-> 3Ze� _ _ E-adjacent property line
D 30' 1rR. RV 3�1
SEASo..i AL I fi
e�K � I HOM& I Gaa�wt z
I j PfiO PostD
1 J
1
VACANT I I If-G ArtAcd
31 V0.oPosCD
-'40'-�I \ �.
I 1
---�t \
so,
% I
/00'
I
tr..eLL
I i
/00' 1
adjacent property lined ; �. c \; Fadjacent pro pert'line
TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.) k-
SAMPLE TOPOGRAPHY PROFILE
LL
d�a1',r,te. to
{ t e a
3
gnature Date
i 11 i
II I1 j
i i I I
it � illfil I Iff _ I
{ iIIII IIII - l � !
i
--
I `
i I
. 10
000
1
FT
I +
1 1 Ilj 11
I
ZZ330-SO `00213
98sgg'
i
� No
t f,
r
N M
G
t
p
XS2 s p
p
I
50.0 Sv.
y
N
fret t
dE � 33�373u a �.
w �3' lid
� H U 33 E vj
31�E -r111 ON
n
3
e�
3E I E ,
E
a
3€J 3
EE €>z
[ kr
,M
W
E 3E 3
�
he✓ .Ki \ \ K 33f - y, 3 3 �` €3'3N
E _ 3.\' 3 ,
ns�✓ � � ...�n "��"a4 E 3 3
h
33�• 3 'n r33
::���1• 3 3 �'� 3 € WE
hk
nwi> .f `E9 tamer, w `� Ean �SiSv,�a h ,. k
... - 3E3"
All
S
3
«r
rE
a< CL
l I
3Y 3x3 !
y
E€H 6,2
a `33>i r tE �? �d
g
•
OD
iK 9 333 . 33 333 E "j�fi r"F�
.� V) � x - hs¢'d43N3 s 3 s 3 s d,
k £ � �` US%i c�n4r E 3
� �r �
rD
/11 t Rai � =CT+r 3� `�
\I/ � '�
T }mow
1 1
r#a `V t-' 3 i" X / Yj333j y\ �£ � 3F'R3 *S9AI"' r f S ,3,3}C 3� SHiC l�S�
s, j' ' E,�a ��� �E �S�3us'
»... - -�.
3(fi33tF c 337 3 /G 3 33
-
i
j)3 / ....lidMM
l y 3�
-�w..*r'�4'"�riu'k»+ M�www.+MME�rwwu'rtfm�wXwe'4�MMNNwn+w+'�.wiMuroW rX E�F,»�x a ..,.s.,L.7 XE +�rSbEF'n xaXm«.�i ;,
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Dwirmmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions ..................................
............... . ....
PART 1: Applicant/Parcel Identification
Name ofApplicant i e t Date
& o T,;, 4'L(�,,�, -8/q.A.5Lt`�Telephone3(o o q ot 3 3
Mailing Address
Assessor's Parcel Number 2 z 3 30 'D
Type o Water Syvem(Check One): Reason for Application (Check One):
0 Public/Community Water System(2 or more Building permit
connections) 0 Land use application,if so..
13 Individual water source(one connection),if so.. 13 Division of land
Well #of Parcels?
13 Spring/surfwe water SPH9 -
13 Other(explain) C3 Boundary line adjustment
C3 Other(explain)_
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water System
Name of Water System
Water Facility Inventory(WFI)Number:
0 The water purveyor has filed a letter granting blanket hookups to this water system.
0 1 am the manager of this water system. The water system has been approved for services. Them are
presently connections in use. Ibis will be the connection.7Ww_ater system is able and
willing to providewater to this(these)connections wlit-Fout-exceeding the.limits of the water system or any
limits set by state and local regulation.
Signature of Water System Manager -Date
H.I WDA TA URCHIM WA TM D3.WP Update:Much 22,1"9
W - 7
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Date LL2410a PO BOX 1666 SHELTON,WA 98584
SHELTON (360)427-9670
FAX (360)427-7798
ELMA (360)482-5269
BELFAIR (360)275-4467
(<�AJ Ve . ` AA 1/ SEATTLE (206)464-6968
9es-w-
BLD2000-0L /! SL Parcel Number 2 2 33 o - o 1,o 2/
Your building permit cannot be issued by Mason County Environmental Health until
the following are completed and tumed in:
❑ Application of Water Adequacy.
Approved septic system records or approved septic design for bedrooms
❑ Complete and accurate scaled plot plan which shows all building(actual &
proposed), driveways, location of septic system, location of reserve drainfield
and wells.
❑ Report within the last three years from either a septic tank pumper or an
Operation and Maintenance Specialist.
❑ Well Log. Ea Water bacteriological analysis. w% r Ae b f/ yee,7.
Copy of a recorded Certificate of Residential Use for bedrooms.(sign
❑ and notarize the enclosed form. Either return the form to this office with a check
for$8.00 payable to the Mason County Auditor or record it yourself at the
Mason County Auditor's office and bring us a copy.)
Other:
a
If you have any questions, please call me at 360-427-9670 Ext 353.
Cindy E.E Waite
�.
Environmental Health Technician
}
i
I
I
APPLICANT NAME I � �C � � ( 6 ( _GATE•
BUILDING PERMIT CHECKLIST
SITE ADDRESS
/ If site address has not been issued refer the customer to Community Dev. ext 291.
(g FIRE DISTRICTS
7� Please make sure the fire district is included in the application information. Refer to map located at counter.
DIRECTIONS TO JOB SITE
Needs to be as complete as possible (i.e. major roads, is house on left or right side of road, etc.). Be sure to read for
clarity (Landmarks, signage, owners name on mailbox, etc.?).
LIEN/TITLE HOLDER
Who holds the mortgage (Bank or name of private owner holding contract)?
CONTRACTOR REGISTRATION #AND EXPIRATION DATE
This Information needs to be provided. The Building Department may be able to research expiration information if
customer does not know it. We ust have a signature in 1 of the 2 boxes, either the applicant or the contractor.
l
ICE SEPTIC RECORDS — <n� - 1 I
TT New systems must have test holes dug prior to submission and Septic Application must be filed and paid in full.
A B
WATER COMMUNITY P
SEPTIC EXISTING & -
i
i
DEV REMODEL NEW
STATUS
IS THIS A REPLACEMENT UNIT? YES NOK—
IF SO: MASON COUNTY BUILDING PERMIT APPLICATION SECTION5,BUILDING SQUARE FOOTAGE, MUST BE
FILLED OUT COMPLETELY.
AND: SECTION #6 MUST CLEARLY STATE, "REPLACEMENT UNIT"
PARCEL# .EGAL DESCRIPTION 1111CHECK PARCEL NUMBER FOR PARCEL FLAGSIIII
Parcel must be included. If number is not available contact Addressing at Ext. 291
BUILDING SQUARE FOOTAGE I
Clearly show existing square footage and that of which is proposed. If there is a garage,verify whether It is attached
or detached. Include square footage information for mobile homes.Ge• 1 OX20=200 square feet.)
USE OF BUILDING
Residence, garage, greenhouse, designate if it is commercial.
(� DES
(i.e. MKobile hgMi addition, addition to a house, etc. . .)
TYPE OF JOB
—(7 Verify appropriate boxes are marked.
WATER ADEQUACY
For new residences and mobiles. PRIVATE WELLS MUST HAVE WELL LOGS OR CAPACITY TEST AND BACTERIAL t
TEST. If they are on a public water system, check for signature to verify that the system is not on the States "out
of compliance Nst"
1
- I
1
r
i
MOBILE HOME INFORMATION
Verify appropriate boxes are marked. If factory order, please put factory Order in MO bne home serial . If unit was
assembled prior to June IS, 1976,refer to procedures handout for"Obtaining Installation Permits for Mobiles
assembled Prior to June 15, 1976."
Q FLOOR PLAN
Manufactured/Mobile homes require a floor plan of the home be submitted.
9 FEE DUE
A fee of $175.00 is due when application is accepted.
This is half of permit base fee of $350.00.
[] SHORELINES/CREEK/WETLAND
If property is within 200 feet Lncludina adiacent properties) of Shorelines/Creek/Wetlands, #9 must be complete. If
none of the conditions are present please enter "na" or "none".
Q SITE PLAN DRAWING MUST SHOW THE FOLLOWING:
• LOT DIMENSIONS - DRIVMAYS
EXISTING STRUCTURES • SHORELINES
t STRUCTURE SETBACKS ` WELLS
SEPTIC SYSTEMS ' NAME OF FRONT STREET
PROPOSED IMPROVEMENTS • EASEMENTS
• NAME OF SIDE STREET
ALSO PLEASE MAKE SURE DIRECTIONAL IS FILLED IN ON APPLICATION
IF PLOT PLAN IS ATTACHED TO PLANS OR IS NOT ON CARBON FORM,
(3) THREE PLAIN PAPER COPIES ARE REQUIRED.
TOPOGRAPHY DRAWING
If property is flat write"flat" on the topography section. If house or structure is near a slope or hill, drawing must
reflect this. This should show an accurate side view of the property.
PLUMBINGIMECHANICAL
This form must be completed for any structure with plumbing and mechanical excluding mobiles/modulars.
OWNER OR CONTRACTOR AFFIDAVIT
Owner or contractor must sign affidavit statement and date it.
13 ACCEPTED BY
Whoever Is accepting permit information must sign your initials and date form on the bottom of page 3 or use date
stamp and initial on back of permit.
13 PRINTS
Need three sets of prints unless it is a stock plan. For stock plans, we only require one copy.
Commercial projects require four sets of plans.
WSEC &V &IAQ CODE
Required for all residential,additions and commercial buildings. Energy Code compliance form needs to be COMPLETED.
Verify heat source (no wood or pellet stoves are permitted as primary system). Window schedule must be filled out
and reflect what appears on submitted building plans. If applicant has decided to go with the PUD In a Long Term
Super Good Cents program, we require a copy of the signed agreement with the utility.
(] ROAD ACCESS PERMIT
If you will be accessing your driveway from a County road, contact the Public Works Department In Mason County
Building 1,427-9670 extension 450. Access from State Highways requires Department of Transportation approval.
Contact office (206)895-4753 (Port Orchard).
CheMist.2
December 17, 1998
2
Trish