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Fall Date date Done By Comments cue o ,SET �Ges , ll o y S)G� P UV"" s �/ .op -o? 1� _ 67 ( c� N I/P/VIA CD S rv'm G � Sa7 a �•, ins t G L�o1n 1 - o-7 1 30 b•7 -rA A j2 C, 1 s ED-7 0 h 1 MASON COUNTY PERMIT NO 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 APPLICff INFORM TION CONTRACTOR INTIRM TIONN {� Owner Company Name All Mailing Address/j �j`i_',� Al 2111`` tvV Maili ddress , Cit Statel -1 Zip Cod City � ' "� j=0 State Zip Code Phone T'-13Mr.Other Ph. G_~� /- L/ ) Phone 3e tea='3 Other Ph. 1 Contractor Reg. V Lien/Title Holder # �s E mail address_A(.-':111 E Mail Address RPye I "� ' ` ^ 12 Drivers Lic.# LA DOB -/I- Gr' Drivers Lic.# i-,3/Nf 97 ?7 f` -7 DOB SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic — Existing Septic Connect to Water System Name of Water System Sewer System Name of Sewer System - PARCEL INFORMATION - 12 Digit Parcel No. Z Fire District s' Legal Descriptio 1 I ?L" 'y' fi Site Address(Please include street name, street number and city) ,1 Dir,4 1e tions to site ''- �j Will timber be cut and sold in parcel preparation?Yes la .�G Is pfoperty within 200'of Saltwater A Y1 Lake River/Creek Pond Wetland�_Seasonal Runoff Stream�Slopes or Bluffs 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑ Use of Building + escribe//Work T No. of Bedroom No. of Bathrooms�/_Square Footage- 1st Floor POO 2nd Floor 1=1L 3rd Floor Basement-//3(-* Deck Covered Deck- Other Sq. ft. Garage Attached Detached Carport-7 Z-G_ Attached Detached ,T MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No. of Bedrooms No. of Bathrooms f 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 d 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 OFAPROGRESS INSPIrCTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. X �✓` � �f xy- Date' ' Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date t` DEPARTMENTAL REVIEW APPROVED DENIED NOTES 0 Building Department c Planninq Department `t Environmental Health Department Fire Marshal or1 FEES C Building Permit Fee T 72 )0, Site Inspection Plan Review Fee EH Review Fee Plumbing & Base Fee l Planninq Review Fee Mechanical & Base fee l s-- S Other Wood/Gas/ Pellet Stove Fee State Fee Y S� Violation Fee /Z" a7 Pre-Paid at Submittal Valuation $ TOTAL FEES 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) 427-960h e Belfa w0)275-4467•Elma(360) 482-5269 web6comason.wa.us APPLICANT INFORMA ION CONTRACTOR INFOr�ATION y Owner �A�U U-'ehArO r-son Company Name -7/4 OL B� N Mailing Addres S Mailing Address.2`''��� �`� or ft 3�0 City Q- h State���Zip Code City PDVL B tate - Zip Code— --- G Phone3l a1 17.5C -Other Ph - /S Phone 3 39'� 770 2 ter Ph. Lien/Title Holder 6�`�^`r��- Frr�-eral Contractor Reg. r,n/F' E Mail Address E mail address Al Drivers Lic.# b DOB -/ — Lv Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION N- 12 Digit Parcel No. 000 Zo hLkl 1 Fire District r Legal Description _ Site Address (Plea lude stre t ame, street number and city) a inc Directions to 'te lIs property within 200'of Saltwater Al v Lake River/Creek o Pond Wetland 420 Seasonal Runoff A ,2Q Stream 7O Slopes or Bluffs > 15%— TYPE OF JOB - New Add Alt Repair Other Use of Building j Location of Fixtures/Units- 1st Floor 2nd Floor Basement Gara P�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 Tvpe of Unit No.o� Fees Bathroom Sink Furnace Bath Tubs Z Heatpumps Showers l Spot Vent Fan T Water Heater 4-1162YN Ccaz Propane Tank Clothes Washer — Gas Outlets Kithen Sinks Wood/Gas/PelletStove n Dishwasher Kitchen Exhaust Hood Hosebibs .-- Dryer Vent 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.Admowledgement 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 RI required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained (� to apply for this permit an cond uct duct the work proposed. The owner or agent on owners behalf,represents that the information permission from them nty access to the above described property and structure for review and inspection. provided is accurate and grants employees of Mason Cou PROOF OF NTI UATIOIN W RK�IS BY MEANS OF A PROGRESS INSPECTION.ZZ a 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 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 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-gg67 •Belfair((360)275-4467•Elma(360) 482-5269 On the we wVwv.co.mason.wa.us A PPLICANT INFORMATION CONTRACTOR INFORMATION F-"rlV2 �-Snn Company Name L� irlo es Mailing Address State (A Zip Code City— Po��6-90 State '`ram Zip Code 2T Phone3«aim�7.SLc Other Pr /S?� Phone 36o 39'- 770 2 ter Ph.. Lien/Title Holder����t� F�"�"�'�I Qn r Contractor Reg. E mail address Alc& E.Mail Address -- Drivers Lic.# rD DOB — 4P 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. Za - Fire District Legal Description I� 1 4-''G At IV , Site Address(Please include stre ame, street number and city) ' — 6g Directions to 'te Is property within 200'of Saltwater 416 Creek A-2 o Pond Wetland-20_-Seasonal Runi =0-Stream--A20 Slopes or Bluffs J 15% ,S TYPE OF JOB- New Add Alt Repair Other Use of Building J Location of Fixtures/Units- 1st Floor 2nd Floor. W Basement Garage LAV Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS X Tyge of Fixture No. of Fixtures Fees Fuel Type:ElectriC__ LPG Natural Gam_ Heat Pump_ Toilets Type of Unit No. Fees Bathroom Sink Furnace Bath Tubs Heatpumps — Showers l Spot Vent Fan Water Heater LCOi Ceizz Propane Tank Clothes Washer — Gas Outlets Kithen Sinks Wood/Gas/PelletStove Dishwasher Kitchen Exhaust Hood Hosebibs _ Dryer Vent �Z Other Other Base Fee Base Fee EL TOTAL PLUMBING TOTAL MECHANICAL O VNER/BULDER Ad=wledges 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 Rt required from any easement holder or any other parry in interest regarding this application or the work proposed in the application,I have obtained (� permission from 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 UATION�WRK IS BY MEANS OF A PROGRESS INSPECTION. X Date: E- 7-7, o? Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYONDTHIS POINT Accepted by: Planning Pd Ck# Date Bid Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Groug—Tyge Constr.- Planning Constr.— Planning Department !� Environmental Health Department FEES Plumbing& Base Fee Site Inspection a Mechanical&Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other E Violation Fee TOTAL FEES i FORM MUST BE COMPLETED IN INK PERMIT NO. PLEASE PRESS HARD MASON COUNTY . PLUMBINGNECHANICAL PERMIT APPLICATION 426 W.Cedar•P.O.Box 186, Shelton,WA 98584 Shelton (360)427-R70•Belfair 360)275-4467•Elma(360)482-5269 n the weep .co.mason.wa.us rMailing LIC//��N� T IN� FORMA'�ION CONTRACTOR INFO ATION er�.e�d�11 �eh tO tin Company Name K ddres Mailing Address tate Zip Code City �o� —State- '`ram Zip Code � Phoned r 7 S�I�� Other P�t - 1-� Phone-360 31f_ �70 2 ter Ph. Lien/Title Holder r10— - x Contractor Reg. E mail address E Mail Address Drivers Lic.# DOB - - <v 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. Zo - Fire District s' Legal Description IQ I +-h c Site Address(Plea a include street ame, street number and city ' - ip Directions to 'te r Is property within 200'of Saltwater Aio Lake -River/Creek A-2 a Pond Wetland A-70 Seasonal Runoff--A. C2 LO S 2Stream_ lopes or Bluffs > 15% f N TYPE OF JOB- New Add Alt Repair Other Use of Building j li Location of Fixtures/Units- 1 st Floo 2nd Floor Basement Gara e-L2C.L-Closet '&0 '! PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS ,_ T,yce of Fixture No. of Fixtures Fees Fuel Type:Electric LPQ-%.- Natural Gas_ Heat Pump_ Toilets Toeof Unit No Fees Bathroom Sink Furnace Bath Tubs Heatpumps Showers Spot Vent Fan Water Heater �1C bi Ccaz Propane Tank _ Clothes Washer Gas Outlets �.— Kithen Sinks Wood/Gas/PelletStove Dishwasher Kitchen Exhaust Hood Hosebibs 12 Dryer Vent EE Other Other I Base Fee Base Fee z TOTAL PLUMBING TOTAL MECHANICAL i OWNER/BUL.DER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.AclnowledgemeM 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 l permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.9 permission is Q1 required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained l� permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information I provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection. PROOF OF t1A� RK IS BY MEANS OF A PROGRESS INSPECTION. Date: S- '7 ? X Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYONDTHIS POINT Accepted by: Planning Pd Ck# Date Bid Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Grou T e Constr.- Planning 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 f Violation Fee TOTAL FEES s Pray 2�3 07 02: 49p JRCK JOHNSON CONST 360 275 4611 p• 1 REGISTERED AS PROVIDED BY LAW AS CONST CONT GENERAL EXP. DATE REGIST. # CC01 RNJCOm*96408 p��26/2004 EFFECTIVE DATE R N J CORPORATION 650 NE STATE HWY 306 P07ULSBO WI), 983* •sU��! `n• T.)"P:\fiTlif�T pF Lrs _._.—__ Look Up a Contractor, Electrician or Plumber License Detail Pagel of 2 Topic Index Contact InfoLabor and Industries 1 Search Mtn Safety Claims a surawce -Ww*� ptue Rights Tr&&s e Licensing Find a Law or Rule Get a Form or Publication I Look Up a Contractor, Electrician or Plumber Printer Friendy�bersio_n General/Specialty Contractor 'A business registered as a construction contractor with Li'tl to perform construction work within the scope g of its specialty. A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance: I License Information License RNJCOC'96408 Licensee Name R N J CORPORATION Licensee Type CONSTRUCTION CONTRACTOR k 602409939_Y_er.fy Workers Comp Premium UBI Status Ind. Ins. Account Id Business Type CORPORATION Address 1 650 NE STATE HWY 308 Address 2 City POULSBO County KITSAP State WA Zip 98370 g Phone 3603401403 Status ACTIVE Specialty 1 GENERAL Specialty 2 UNUSED Effective Date 9/28/2004 f Expiration Date 9/28/2008 Suspend Date Separation Date Parent Company Previous License f E I Next License I Associated License I https:Hfortress.wa.gov/lni/bbip/Detail.aspx?License RNJCOC 96408 6/18/2007 t a' I zit. lzO Jf o R X f0 -� � �, � � o�. " .jam• a Ao o J . � �`` .� �'���� L;�� � ,arty �• ;.,., (11 �e I v� 5 a _ � a ti • Cps -��� (�, 'C. l L _. ./ _'. •• OaSEWATICO 1"O rY �•'9K D-I30K • �• 1 A � CD v gc.GaF- z Name a�i �� -j..�:Q- m � Lo Date w o co �n Tax # 1M1-11-00020 � '= O I U a r J N z a• (D 4 N � m MASON COUNTY JIB - 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. C tpt+3t -Part 1 Wo deW.,m1h6tierl can be made uni t Fart 1'to fully co ted. Cfiplete only the port� n-b#Pert applying tQ the ty +eterayaterrr utittzec9. let.4 . `. : ib` 'en,wig chrnet is to ahem er riae r reviler+v. PART 1: Applicant/Parcel Identification Name of Applicant /�y�i�,��a2� .�• /�G�✓� rr!Date -s / y 0 / Mailing Address/`2 A"6x `Sys Telephone=z�0 S2- y� Assessor's Parcel Number . 3 f /l —0 0 6 20 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.. Well #of Parcels?--- SPL Spring/surface water ❑ Boundary line adjustment ❑ Other(explain)_ o Other(explain) **If you have more than one residence ❑ Replacement(please indicate name of water system connected to this well, check the Public box below if 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 !' S 6�,V � J L L Water Facility Inventory(WFI) Number: G :7 L/,' e) (write"none"for two party) ❑ I am the manager of this water system.The water system has been approved for .Z services. There are presently / connection(s)in use.This will be the _connection. ❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system(ie:recreational to full time).Please indicate on the following line the nature of this change: This water system is able and willing to provide water to this(these)connection(s)without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manage Date `S D Update:April 2006 Individual Wafer Well Water well report(attach to application) Depth Well capacity test(attach to application) __gpm __,__gpd e well dHiler often pertorms well capacity tests at the time the well is constructed. esu s 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 bythe applicant orif 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 bv 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 can provide at least 800 gallons per day and/or provides water at a rate of 2 gallons per minute based on the following observations. AUTHOR OF STATEMENT_ _____DATE RELATIONSHIP TO APPLICANT IN ADDITION TO PROVIDING 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. OMT 3.,H", -t ®?gip >rti -001t.Etii ty9tion (Staff l 4,0n*) uATI F TC F Y L iTTEF2lVtINATIC N: Applies' s mi ter supply appears adequate,to r>het e�nee c f to Arttended use. This tllter`llrflzn `` t address adequacy,pfthe dstribut©n syst e ,gealrftee an actetuate idly water lradefin�tely�n#a the future, crr gur; ree cortapliance Witt)4W ii able t bE water resaurca regal tl ns.; UNSATt ,,AC'C RY aE�ERMINATION:Ap is n"#'s water supply does not appear adequatt,to meet the needs of its intended d ' for the following reesnn (s): REVIEWER'S SIGNATURE DATE Update:April 2006