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BLD2006-01821 Final Replace Mobile Home with SFR - BLD Permit / Conditions - 10/9/2006
o CONCRETE MECHANICAL KANUFACTURED HOME y N o Date �7 B}l Z7 Footings/Setbacks Ribbons CP Gas Piping C) Interior Date By Interior-Date 07 By,�; c}u Date By C N Exterror Date // �(o By //S Exterior-Pate - -p 7 B Stet-up Cn Point Load I Isolated Footings INSULATION pate By � BG f SLAB INSULATION L Date By Data f 6-- t77 By LJ FIRE DEPARTMENT > Foundation Walls Floors Date By M Date By Data By DECKS Cl) FRAMING Walls Date By Date - B Data��/. By,j �+ PROPANE TANKS PLUMBING vault Data ��a'.0-90 By Date By OTHER Groundwork Atdc Date 3 �2�, ByTj Data ��- B r lType: p •Doe By D.W.V DRYWALL Type: Int.Brace[Nall Date By. W D a te6e— By Date By FINAL INSPECTIONID p Water Line Fire Smporatlon N Date - �`� 13 y� Date13 y Data 9 2�1`.� BY M o J" ID Pass or Request Inspect. c Type of Insp. Fail Date Date Done By Comments N m fSi$ c�Ss s /1471::;;6 TM CD u,��(��-� 0dri0— 343- 3-16-6 8 a �. 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E � - c c / = � a % � \ / \ ) / ff / $ 2 $ CD -0 R § �d ¢ C \ ZZ ( f S. CD T CD � / k C m � ƒ 0 0 C'D £ � E f § 78 ; = § C ) ƒ / 0 7k t m � i 2 JJ7 q . 2 a . 7 t � C� 2 $ JCL < CD k � c \ C� \ e ¢ 7& 8 CD o gG $ / a � E m ¢ � k0 ° � � / f \f \ � � 0 � R / a 0 / /k C kk � 2a COD 0 ID . a0 0 / § § CL CD CLT CO) [ & %$ � CA \ 8 a CD [ ° n -- 3 o PG ] � C: � [ 9 k m $ g ( E E { MASON COUNTY PERMIT N&� �-" 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 APPLIC/jNT INFORMATIO�4� CONTRACTOR IN ORMATLON Owner . AMPS W tN1coLc- PAfZK-Ny/LST- Company Name Lc'` Mailin Address,P 0 Box 1163 Mailing Address City IL State WA Zip Code 9 s -3 City State Zip Code Phone -S O- D- 7LI13 Ol�trher Ph. 3 D -225- S7o9 Phone Other Ph. Lien/TiHc Holder 4A� N/cam- A v 7- Contractor Reg.# Exp. Email address 14rE5A/AJ1C 01 ASAI-"^ E Mail Address Drivers Lic.# f MKN.1WZ5Y/P/3 DOB -O -7S5— Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Wa ystem Name of Water System Well Water System Name of Water System PARCEL INFORMATION- 12 Digit Parcel No JI 3 - -000oo Fire District 03 Legal Description SEA AZZACHED Site Address(Please include street name,street number and city) 223 /hot✓ LV Directions to siteE80M A6_1-F,4'P o7_4k'C- SHoer/NS RIGR o•v SANtj4lu- 26,1e-"7- " 6RFAik AA N ! MILL-0 [.EFT T Aj I-Al 021✓EW-1Y AT C,Vbo LE—FT Will timber be cut and sold in parcel preparation?Yes o Is property within 200'of Saltwater Lake 4 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?Y904 TYPE OF JOB-New-XL-Add Alt Repair a NCECY S S AL Use of Building Describe Work No.of Bedrooms No.of Bathrooms Square Dotage-1st r )DW ElPt. 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage JSL54ff Attached Detached Carport Attached Detached MANUFACTURED HOME INFO ON-Make el Year Length Width iAl No. No. of Bedrooms No.of Bathro s� Type of Heat Purchase Pric Replacement Unit? Yes Installer Name Certificatio pyyNER/BULDER Advmowledges submission of may i—t n a stop work order or perm revocation.Admowledgement of such is by signature below.I declare that I am the owner,��yy��eerr��,, ntative,or the oorrtrador I furtimer declare that I am entitled to receive this permit and to do the work as proposed in the application.Uttdd obtained the permission from all the necessary parties.If permission is required from any easement holder or any other party In irmterest regarditg this application or the work proposed in the application,I have obtained permission from them to appy for this permit and that the information prm7vided is accurate and grants employees of Masdasa property and strrxtiure for review and iispection. PROOF OF CON71NUATION OF WORK IS BY MFJWS OF A PROGRESS MISPECTION. X QQ„ ee ---;/ Date- 10- 09-0 6 Owner/Owners Representative/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 Public Works Department Fire Marshal FE S 7— Buildina 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 �I I MASON COUNTY PERMIT NO�� lo—"O 1 fC C 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 APPLIC NT INFORMATION CONTRACTOR INFORMATION Owner fit/ /Vlco(,E P4aX-NV9S7- Company Name Bw,415 Mailin Address PQ 110K 3153 Mailing Address City state WA Zip Code 9 S28 City State Zip Code Phone 3 C- �-Sl er Ph. 3 -2 $'�q Phone Other Ph. Lien/Title Holder 1 A Es f Niccx.E' - Contractor Reg.# Exp. E mail address- At+ESAWIC OR A6,V4 COAA E Mail Address Drivers Lic.# 1tw2 DOB /D -o 2-7S` Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Wa ystem Name of Water System Well i Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No / - Fire District #3 Legal Description SEA' 47'r�FcHED Site Address(Please include street name,street number and city) 22 AOW Lit! Directions to site FROM. P3ECFi4ik j 7AA-F . A—iN SaoA 4-R6,RIOT o.v SAarD1NLL 260 LEFT oN BEZFA»P A/ ► C.E-FT AT 40id LAB/. WAffV 4Y 4T Cwb Ok A0,46 PAA LE Will timber be cut and sold in parcel preparation?Yes o Is property within 200'of Saltwater Lake 4 River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > IS% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Y TYPE OF JOB-New Add Alt Repair NCEMMI OM Use of Building Describe Work (YB04- No.of Bedrooms�_No. of Bathrooms_L Square ootage-1 st • 2nd Flo r 1261 or 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFO ON-Make el Year Length Width tort No. No.of Bedrooms No.of Bathro Type of Heat Purchase Pric Replacement Unit? Yes Installer Name Certificatio OVER/BULDER Admowledges submission laLemay result in a stop work order or permit revocation.A*nowledgement of such is by signature below.I declare that I am the owner ,,Qy erg ntali ,or the contractor.I further declare that I am entitled to nx*m fhis pembt and to do the work as proposed n the applcation tltJdddcb obtained the permission from all the necessary parties.If permission is required from any easernent holder or any other party In Merest regarding this application or the work proposed In the applicalm,I have obtained perrission from them to apply for this oyperrn it and owner or agent on owners behall,represents that the nfonnation provided is accurate and grards en��lc of desp�ed property and structure for review and inspection. PROOF OF CO=A OF IS BY MEANS OF A PROGRESS INSPECTION. X sz;w r �/ Date: 10-Ocl-O(6 7� Owner/Owners Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted b . Date DEPARTMENTAL REVIEW APP OVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Buildina Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing&Base Fee Plannino Review Fee Mechanical&Base fee l 7- Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee D 4 Pre-Paid at Submittal Valuation$ q S TOTAL FEES MASON COUNTY PERMIT NO�� 1p— O f� 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 APPLIC NT INFORMAO CONTRACTOR INFORMAN Owner w N,iaLe- P421-NV#Z ST Company Name Owl Mallinq Address P© &OK 116 3 Mailing Address City _State WA Zip Code 9 SZ l City State Zip Code Phone *SW- O- Other Ph. 3 -275- SYo9 Phone Other Ph. Lien/Ttie Holder � PARAIW 7- Contractor Reg.# Exp. E mail address R,"0NN1C ASN.C4^ E Mail Address Drivers Lic.# f41ZnAWZ5y& DOB ! -O --?F Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Wa r'System Name of Water System Well Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No -g0000 Fire District #3 Legal Description SE-C .477ACRED Site Address(Please include street name,street number and city) 22 ihob✓ Li1J Directions to site FAOAA ACt-FAik 0 Takt^ "47H 5Hoo2F R6,RIGwr ov SAV64iLL 26 A Q-FT o y SRFAik N ► FT AT glOW Z-A). DaIVEWAY AY CAIb o L Will timber be cut and sold in parcel preparation?Yes o Is property within 200'of Saltwater Lake 4 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?Y TYPE OF JOB-New Add Alt Repai Me& MES Use of Building Describe Work No. of Bedrooms No.of Bathrooms_Square outage-1st or 1DIIV sg - 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage JI&AV&Attached Detached Carport Attached Detached MANUFACTURED HOME INFO ON-Make el Year Length Width al No. No. of Bedrooms No.of BathroType of Heat Purchase Pri Replacement Unit? Ye Installer Name Certificatio OVNNER/BULDER Adatowledyes submission may result in a stop work order or permit revocation.AdamaMedgement of such is by signature below.I dedare that I am „gyyQer�, t�errtabve,or the contractor.I further declare that I am enNed to receNe this permit and to do the wok as proposed in the �ltldd�cb obfalted the permission from all the necessary parties.If pertission is required from any easement holder or any other party In Interest regarding fitls application or the work proposed In the appficall m,I have obtained per>issiof from them to apply for this pemtit and �p rl�p�yepp owner or agent on owners behalf,represents that the information provided is accurate and grants employees of M�descxbed property and siruchme for review and inspection. PROOF OF CONTNUATION OF WORK IS BY ME=A PROGRESS INSPECTION. X sz7za � Z✓ -�+ Date: 10-09-O 6 Owner/Owners R resentative/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 Public Works 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 I MASON COUNTY PERMIT NOC- (Q 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 wwwco.mason.wa.us APPLIC NT INFORMATION CONTRACTOR INFOORMAWN Owner w N,coc.f P42kFf V2 5T- Company Name Mailing Address .P© go 1153 Mailing Address City State W Zip Code 9 2 8 City State Zip Code Phone 3 0- 0- 3 Other Ph. 3 D -225- 569 Phone Other Ph. Lien/Title Holder A^� 1c0G - A v �' Contractor Reg.# Exp. E mail address '141"ESAWIC 01 ,416 /,CoM E Mail Address Drivers Lic.# KNAINZ DOB ! -O -7 Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Wa r'System Name of Water System Well Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No / -30060 Fire District #3 Legal Description SEE47-iA- cmQ Site Address(Please include street name,street number and city) 22 1%ow LAl Directions to site F/zoAt, AEcF4ik., 7A- *- - �aQ7N 6H2.t-0r RAjZ11#q- O v S44jtjAlt.L 2t,+LEFT oN Q BEZFAi LCA7 AT 420LW G.J. 00vc"y AT Eyb ok Rv a FAA L Will timber be cut and sold in parcel preparation?Yes No Is property within 200'of Saltwater Lake 4 River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Is this pennit submittal the result of a Stop Work Notice,Correctlon Notice or other enforcement action?Y TYPE OF JOB-New Add Alt Repair 0 &MNCE MM Use of Building Describe Work No.of Bedrooms___L—No.of Bathrooms I Square Footage-1st or 1D61 52 - 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage c1fre Attached Detached Carport Attached Detached MANUFACTURED HOME INFO ON-Make el Year Length Width M No. _No.of Bedrooms No.of Bathro Type of Heat Purchase Pric Replacement Unit? Yes Installer Name Certificatio OVN*R/BULDER Advrowledges submission d My.—in a stop work order or pemfit revocation.AdexWedgernent d such is by signature below.I declare that I am the ovunar,,,QQyy��eerr��,, entad" or the oonbactor.I further declare that I am entitled to receive this permit and to do the work as proposed n the application Utlddd� obtained the permission from all the necessary parties.If permission is required from any easement holder or any other party In Merest regarding fhis application or the work proposed In the application,I have obtained perrnissiort from them to apply for this permit and rl owner or agent on owners behatl,represents that the Information =provided is accurate and grants employees of Mas� �M1��6v�desaibed properly and&uck re for review and Inspection. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS NSPECTION. x S —41 Date: 10-09-O 6 Owner/Owners Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted b . i Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department TT N In Planning Department Environmental Health Department Public Works 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 MASON COUNTY PERMIT NO�( `-' � (O 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 APPLI INFORMATIO��N CONTRACTOR O CTOR INFORM Owner-h A AC"S W f rylco(C_ P41LIc'NVje ST' Company Name �'` Mailin Address P© oK 3153 Mailing Address City State WA Zip Code 9 SZ 1 City State Zip Code Phone '3 D- D-$'Z 3 Other Ph. 3 -275 2§2y Phone Other Ph. Lien/Tile Holder AMPS icot.E A u ST Contractor Reg.# Exp. E mail address J,11""AWIC CP^-W-COAA E Mail Address Drivers Lic.# .NW2 DOB /0 -0 2-2- — Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Wa r'System Name of,Water System Well Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No 12%3a-11-00000 Fire District 03 Legal Description SEK 477Acgebi Site Address(Please include street name,street number and city) 22 Mot✓ Lit! Directions to site FA Mo RELF41k ; 74ke- "A7N SHoAr A6,R1614T ON 34-vb114LL 26+LEFT oar) MZFAue I L7 ow I_Aj. oaIVE 4 ewb o L Will timber be cut and sold in parcel preparation?Yes o Is property within 200'of Saltwater Lake N River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% Is this permit submlttal the result of a Stop Work Notice,Correction Notice or other enforcement action?Y TYPE OF JOB-New Add AR Repair NCE S AL Use of Building Describe Work No.of Bedrooms No.of Bathrooms Square ootage-1st r )DW 142- Pt 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFO AAA&-Make el Year Length Width lal No. No.of Bedrooms No.of Bathr�e� Type of Heat Purchase Pric Replacement Unit? Yes e/ Installer Name- Certificatio OIIYNER/BULDER Adavwledges subrrdSsion may result in a stop work order or permit revocation.Aciewwledgernent of such is by signature below.I declare that I am fhe owner,, tive,or are contractor.I further declare that I am entitled to recalm this permit and to do the work as proposed in the application Altlb iq�obtained the perrnission from al the necessary parties.if perrnission is required from arry easement holder or any other party In Merest regarding this application or the work proposed In the application,I have obtained pw*s h from them to R for 1h andN oQr3 q owner or agent on owners behalf,represents t1ul the information _ is accurate and of IasaNPGow" desaUed property and shMre for review and inspection. PROOF OF CON MATNON OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X �Q.ustd Date: 10-09-0(6 Owner/Owners Representative/Contractor indicate which one a FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date_ffil ff. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department t0 3t Environmental Health Department Public Works Department Fire Marshal FEES Buildina 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 lit FORM MUST BE COMPLETED IN INK PERMIT NO.� PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar•P.O. Box 186, Shelton,WA 98584 Shelton (360)427-�P70 eB1elfbairw(v860o2mason6wa.usma(360) 482-5269 APPLICANT INFORMATION S CONTRACTOR INFORMATION Owner NA.-Ir-S eNJCvLc- PA,?-"ye /_ Company Name mailingAddress O BOk t S� Mailing Address City LztC,4i2 State WA Zip Code 9 8-SZy City State Zip Code Phone I(00 - 71 D- SfZOLhe r Ph Phone Other Ph. Lien/Title Holder E s P-4&/r•Nu2 S 1 Contractor Reg.# Exp. E mail address E Mail Address Drivers Lic.# P•4ekn )W 2,Szf P6 DOB 2 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. Fire District Legal Description Site Address (Please include street name, street number and city) 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— LPG_ Natural Gas_ Heat Pump— Toilets 1 Type of Unit No.of Units Fees Bathroom Sink 2 Furnace Bath Tubs f Heatpumps Showers Spot Vent Fan Water Heater Propane Tank 1 Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PelletStove 1 Dishwasher Kitchen Exhaust Hood 1 Dryer Vent Hosebibs � 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 as proposed in the application. permit and to do the work 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. PROOF OF CONTINUATION OF W K IS B F A PROGRESS INSPECTION. �✓ Date: I O- O`T' 000 X Owner/Owners Representative/Contractor (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 Groug)-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 MASON COUNTY PERMIT NO.v`' PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar-P.O.Box 186, Shelton,WA 98584 Shelton (360)427-9670-Belfair(360)275-4467-Elma (360)482-5269 Vn the w b www.co.mason.wa.us APPLIC NT INFORM#TION CONTRACTOR INFORMATION Owner A," , S -Vr t1t F �.4�2�'Hv<25 Company Name Mailin Addres O vX ' S Mailing Address City ���F'`;i2 tate t✓� Zip Code City State Zip Code Phone 3 0 - /0- cdZ d�ier Ph Phone Other Ph. Lien/Title Holder N4,-jts, V,42k-14vZ? S / Contractor Reg..4 Exp. E mail address E Mail Address f Drivers Lic.# A ek-N -W Z S L/& DOB 16 d 2 '7 Drivers Lic.# DOB G SEPTIC INFORMATION - Connect to New Septic. Existing Septic Connect to Sewer System Name of Sewer System `t PARCEL INFORMATION- 12 Digit Parcel No. Fire District j Legal Description Site Address (Please include street name, street number and city) i Directions to site { Is property within 200'of Saltwater Lake- River/Creek Pond Wetland Seasonal Runoff Stream—Slopes or Bluffs > 15% f TYPE OF JOB - New Add Alt Repair Other Use of Building V Location of Fixtures/Units- 1 st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures y ` Fees Fuel Type:Electric—_ LPC� Natural Gas_ Heat Pump_ Toilets Type of Unit No. of Units Fees Bathroom Sink �— Furnace Bath Tubs Hea um s Show — �"—"— Spot Vent T Water Heatert L pb Propane Tank Clothes Washer Gas Outlets Kithen Sinks Woods Pellet Stove Dishwasher t Kitchen Exhaust Hood ___F_ Hosebibs Dryer Vent f Other Other Base Fee Base Fee TOTAL PLUMBING—, TOTAL MECHANICAL 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 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. PROOF OEDON71NUATION OF W K I A PROGRESS INSPECTION. �....,. �✓ Date: J O- o 9- p 6 X Owner/Owners Representative/Contractor (indicate which one) I FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Grou T e Constr. Planning Department Environmental Health Department ES Plumbing& Base Fee Site Inspection j Mechanical&Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other j Violation Fee TOTAL FEES FORM MUST BE COMPLETED IN INK PERMIT NO. _ 1 Y PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL 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 we www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner lA ^#-S &1 C L6- P.�42k v/1 S% Company Name Mail'n Address PO dOk 31 S3 Mailing Address City ��f=,412 Mate WA Zip Code.9 S-S-Z!W City State Zip Code Phone 346 - -7/0' W er Ph Phone Other Ph. Lien/Title Holder A-"E S i�i4/Z*-"Utz S i Contractor Reg.4 Exp. E mail address E Mail Address Drivers Lic.# i2k1.1 )W 29YOS DOB -0 2 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. Fire District Legal Description Site Address(Please include street name, street number and city) 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- 1 st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Tyge of Fixture No. of Fixtures Fees Fuel Type:Electric LPC Natural Gas—_ Heat Pump_ Toilets 1 Type of Unit No.of Units Fees Bathroom Sink 2 Furnace Bath Tubs f Heatpumps Showers Spot Vent Fan Water Heater Propane Tank 1 Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PelletStove 1 Dishwasher .—L— Kitchen Exhaust Hood Hosebibs Dryer Vent 1 Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OWI4ER/BULDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Advtowledgement 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.N 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. PROOF OF CONTINUATION OF W K IS B F A PROGRESS INSPECTION. X --7./ Date: 1 O- O'r- 0(, Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. 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 PERMIT NO. ` MASON COUNTY PLUMBING/MECHANICAL 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 INFORM#TION %`+ _ CONTRACTOR INFORMATION Owner. Company Name ! ' -'� 1 Mailing City MailingAddress9 Address D(. j:"4 `z State t'`-4 Zip Code City State Zip Code Phone l� 4s4 r` er Ph. _ Phone Other Ph. Lien/Title Holder �"'c ' '�` `t f' / Contractor Reg.# Exp. f E mail address E Mail Address i Drivers Lie.# I'�k'°` SY/ri�; DOB NO°' 7 S Drivers Lic.# DOB SEPTIC INFORMATION -Connect to New Septic Existing Septic. Connect to Sewer System F Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel No. Fire District Legal Description Site Address (Please include street name, street number and city) Directions to site i Is property within 200'of Saltwater Lake River/Creek Pond f Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% TYPE OF JOB - New Add Alt Repair Other Use of Building Location of Fixtures/Units - 1 st Floor 2nd Floor Basement Garage—Closet I j PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS TVpe of Fixture No. of Fixtures Fees Fuel Type:Electriq _ LPCz_ Natural Gas_ Heat Pump_ Toilets �— Type of Unit No.of Units Fees Bathroom Sink �— Furnace Bath i Heat um s Showers s Spot Vent Water Heater �_ Propane Tank Clothes Washer T_ Gas Outlets Kithen Sinks Wood/Gas/PelletStove�— Dishwasher �— Kitchen Exhaust Hood �— Hosebibs 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 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. PROOF NTINUATI N OF'�*'""K Ip A PROGRESS INSPECTION. X ''� Date: / 61- Owner/Owners Representative/Contractor (indicate which one) I FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. j DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Group-Type Constr. Planning Department Environmental Health Department i FEES Plumbing & Base Fee Site Ins ection Mechanical& Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES Permit Tech Checklist COUnLROAD OR PRIVATE ROAD? AD A LESPERMITExisting? New? Applied For? Approved - RAP PRIVATE ROAD - —, Within 150 feet of County Road? Yes No No — needs review by Fire Warden SEPTIC SEPTIC DESIGN APPROVED - Yes / No PUBLIC SEWER SYSTEM? - Yes/ No Required to show proof of connection fee paid prior to issuance of building permit. WATER ADEQUACY PRIVATE WELL— Well drilled?DYes No Waiver required? COMMUNITY WATER SYSTEM —Yes No Signed by water manager? SITE PLAN Check for previous SPI's or RLC's to determine if any critical areas need to be addressed up front, i.e. wetland delineations/ geo tech reviews. It ;?} `: :) �{i � ( ;• �. �� Y; •. 146 eSL LOCAL FILE NUMBER CERTIFICATE OF DEATH STATE FILE NUMBER ..: Last 2 SIX(M/F) 3.DEATH GATE(sAo.Day.Yr) 1.NAMEFeu Male Jul 30 1992 Jeffre Donald SMITH WASDECWEMTEVERT��Lewis COUNTYoFI7FJITH 4.AGE LAST BIRTH- 5.11NDFA 1 YEAR 6.UNDER 1 DAY 7.BIR HOATE(Mo.Day.Yr) 9.BIRTHPLACE W U.S.ARMED FORCES? G� DAY(Yrs) Mob RATS HwBs McNS (C4v.Slue a Faegr Caney) lees�No) NO 30 i une 7 196oaWAt3 SMOKING 1 t.CITY.TOWN OR LOCATION OF DEATH 12.PLACE OFDEATH-bD BOX FOR PLACE THEN CANE ADDRESS OR MISTIMION NAME 15 YEARS?(Yes/NO) 1.O HOME 20 NTI1M MiT L O EMBIL M Wf PIN 40 ROSP. 50 MIR NW 6)Q OTHM PACE +M r Forest Service Rd. 4725 '/2 mi. fran 47 Rd. No Packwood I&SOCIAL SECURITY NO. - 17.DECEDENTS EDUCATION 14.MARITAL STATUS-44wrwd, 15.%HIVING SPOUSE(d•�•G^p M&dert twat) (SWAY prey NO-gram 0-plowd) Never Marred.Widowed. y, Diwrad(SP�M) EbrwrVaryASecOrtdary(Ot2) Co"(tom or 5.) Never married 533-76-0565 12 or Owwe( ►)(SWCM 2t.RACE(SDee+IY) 16.USUAL.M.1 nON(Give O N d r ark dare 19 KIND OF BUSINESS OR INDUSTRY Yes or WPM Yes.Weci1Y CubM Me"iwn.P-w RcM MI '.. durdl9 rust d vgranp We.DO NOT USE RETIRED) _.. Pi of itter US Naval Shi and (Yes I NO)SpWifY: No White 29.aIYrtOWN.00LOCAT10N:Y4 WSIOE CITY COUNTY M.LENGTHOF 26.STATE 27.ZIP CODE 22.RESIDENCE-HUMBER AND STREET .. .. _...... U IM PAS.W CO. �t (Yes/►Nco WA 98528 200 Moe Lane Belfair No Mason 5 rs. 2H.MOTHER'S NAME-FMT,MIDDLE,MAIDEN SURNAME A'. ze.FATHERS NAME- flRST,MIDDLF_LAST Carol Jo ce Hardan Donald Clair Smith 3t MNL)NG AOtYiESS S'TREST:OR RFD NO. CITY OR TOWN STATE ZIP h 3o.INFORMANT-NAME ;, Father: Donald C. Smith P Bax 5112, Belfair, WA 98528 35.LOCATION-CITY/TOWN.STATE 32.SURIAA.CREMATION 33.DATE(Mo.O .YO 34.CEMEIERYICREMATORY-40MEOft. • REMOVAL,OTHER(SpecdY) r=` Burial q.7 1992 3B.ADDRESS OFFACNLI • 1 36 FUNERAL TOR T 37.NAME OPFACILM r MOLES FUMERAL H014E 0 BOX 279, FERNDALE,WA 98248 TO BE C • ED Y COsilirlMY MIYfICNAM TO BE COMPLETED ONLY BY"""•'••KKAWMa 011 COwOMfw s 39.TO THE SETT OF MY KNOWLEDGE,DEATH OCCURRED AT THE TIME.DATE MID PLACE.. 43.ON OF o PLACE AN AND/ORETO INVESTIGATION.W MY OPINION DEATH OCCURRED AT AND WAS DUE TO THE CAUSES)STATED. DATE MID PLACE AND WAS DUE TO THE ATED. SIGNATURE AND TITLE n Coroner X 45.HOUR OF CHUM(24 M) 40,DATE SIGNED(Mo..Day.Yr) 41.HOUR OF DEATH(24 Hrs,l Clb•• Au ust 4 1992400 PRONOUNCED DEAD(Mo,OSY.YO 47.HOUR PRONOUNCED DEAD 42.NAME AND TITLE OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIF3(iTYW Qr Print) (24 Ms.) i Must 1 1992 0854 4&NAME AND ADDRESS OFCERTWIER-PHYSICUW MEDICALE%AMWERORCORONER(Ty}Ro4PMa, 98531 FYENLAABER Terry L. Wilson PA-C. Coroner. 8 H of Rd. , -Centralia. WA 5a.ENTER THE DISEASES.INJURIES,OR COMPLICATIONS WHICH CAUSED THE DEATH_' I,NyERYAL BETWEEN ONSET AND r- ` IMMEDIATE CAUSE(Firet diseasedGunshot DEATH ;.M md6iaR Bsuluq in d�tlll. A . I THE MODE OF INTERNAL BETWEEN ONSET ANO DUE TO. AS A CONSEQUENCE OR I DEATH DO NOT ENTER T ,( DYING,SUCH AS CARDIAC OR 1 RESPIRATORY ARREST,SHOCK DR & INTERVAL BETWEEN ONSET AND HEART FAIAILURE UST ONLY ONE CAUSE EACH UNE DUE TO.OR AS.A CONSEQUENCE OFFIDEATH SWlwntialb list fonilftl&II 711y, C. wadmil to mosciale c&G&Erder : INTERVAL BETWEEN ONSET AND UNDERLYING CAUSE(Dise=or DUE TO.OR AS A CONSEQUENCE OF: - DEATH i injury which mdi*d evem rE&ON D. in dun)LAST. 53.WAS CASE PFFFAAED TO 51.OTHER SIGNIFICANT CONohTIONS-•CONOm RIB ONS CONTUTWG TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN ABOVE: 52.«/ MEDICAL E%AMWER OR No CORONER?(Yes/Noll Yes 54.ACC.SUICIDE.HOM.•UNDET.. 56.INJURY DATE(Mo.Day.Yr) 5&THOU'OF WIURY 57.DESCRIBE HOW KAM OCCURRED: OR PENDING INVEST.(SpeaiN) " Suicide July 30, 1992 1400 Self inflicted gunshot to head. :M sr Y M 58.INJURY AT WORK? 59.PLACE OF iwM-AT HOME FARM.STREET.FACTORY.OFFICE 6Q LOCATION RF -STREET OR D NO..CITY/rOMM.STATE (Yes INO) SLDG.ETC.(SWdY) Forest Service Rd. 47251h mi. fmn 47 Rd., Packwood, WA No Woods al DATE RECEIVED(MO,.001.Y1.) 61.RECORD AMENDMENT(Re9wer use aft) 82 REGISTRE _ AU6ITEM REVIEWED BY DATE SIGNATURE i- P 4 1992 x All, . OOHttP0o0 (TW.7At1 llamsrryD6H39•t50) FOR INSTRUCTIONS SEE BACK AND HANDBOOK A IICR DTOD3'(7/89) PARCEL 12330-21-OOOOOBUILDING PERMIT PLOT PLAN Found 3/4 " iron pipe with plastic survey plug set dfi centerline of road R/W I by Johnson during survey recorded in Volume 2 of'3hrveys at Page 149. E I 1 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT WSEC/VIAQ Compliance Application Owner: J .tiE � Telephone: l0 2 Parcel#:J2330-Z/ -Up000 Type of project (X) New Residence ( )Addition ( ) Remodel Total Sq. Ft. 15 Floor: nd floor: Heated Basement: of heated area:: Heating System Type: O Electric wall heater O Electric Central Furnace O LPG Furnace O Heat Pump with electric furnace O Heat ump with gas f mace O Boiler, specify fuel type: ther:S eci �_� Glazing UO Prescriptive O tion 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 sing 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) Totov Manufacturer Room/location U-Factor Size Quantity Sq upre Feet Windows: I E Windows: Total Sq.ft. Doors: Doors: Total Sq. Ft Total window and door area Total window&door area /(divided by)total sq.ft of heated area = %of glazing , 4 Mason County Planning Intake Checklist Owners Name: Date: CIq 16 Project: Reviewed By: v Commercial Developm : Y NO Comments: PLANNER: GBM TSC MM M PBC RDH Sit Ian: Ngdh Arrow roperty Dimensions: X Sb' 1 streets and Driveways Shown. Road name: '1� ) ."ll Existing Structures shown with setbacks ;well Location, Septic and Drain-field Shown with setb ,g,-Mentify all surface water (streams, ponds, shorelin wetlands, natural or historic drainage, defined drainage ditches) r ,Topography (slopes) t posed Structurpe Setbacks (Direction/ back): } F: 4(acondition `�nS1:Utility and Drainage EasYes No (if yes enter condition #5022) Other Easements Accessory Appurtenance / Heatpump Variance a lie pp d for. Ye parking spaces allotted? Y4 No County Access Permit Nee #0010) State Access Permit Needed (add condition #0020) Standard Conditions to be added to all Building permits that planning reviews: #5019 and #0700 Site Access: Are there any impediments (dogs/gates) that my restrict access to your site? Is the site clearly marked? How? Address ❑ Name Critical Areas: ► ❑ Other: Setbacks: Shoreline: Slope: T P Shoreline Designation: Comprehensive Plan: RuV Zoning: ❑ Not Applicable ❑ Agricultural H' RR 2.5 10 20 ❑ Urban ❑ In-holding ❑ RMF ❑ Rural ❑ LTCFL ❑ RC 1 2 3 ❑ Conservancy ❑ Rural ❑ RI ❑ Natural ❑ RAC ❑ RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT e ❑ Urban Growth Area ❑ MPR ❑ Unknown Unk wn Water Body (type oftyiaterif unnamed): SEPA: Yes/ No U _-ow Flood Plain: YES/NO � no Map# { I Aquifer Recharge: YES/NO known Map# Tags/Cases: RLC/SPI Case: _U1� - 6-Year Dev. Moratorium: Yw Eagle Nest Tag: YES/ 0 Other Y Revised: 09-29-2006f; i I= o� 60' � • Of 00 � w to t t Co C r Q rn o n A'yi Z , .> m. m = t r �irl L -7 33 3' _ z RL rn s �� t�l' 40'6 ACCESS &GRADE WORKBHVET pg•�; ADDRESS a 3 JZD)f s SLD OR4WAY ACCESS Len • l2 Size of tum-am ad: GRADE,OF DRIVEWAY ayn OP Rnpp ROAD ACCESS Length: Width: Surface Condition: Veracal dearance: (_) BURN PERMIT REQUIRED FOR LAND CLEARING FIRE. LOT INSIDE SMZ, 4X4 FIRES ONLY. LOT INSIDE UGA, fig OUTDOOR BURNING PERMITTED. LOT TOW SMALL FOR: BURN PERMITS 4X4 FIRES. REMARKS---------------