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HomeMy WebLinkAboutBLD2005-01441 WATER ADEQUACY - BLD Water Adequacy - 8/18/2005 FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO. PLEASE PRESS HARD BUILDING PERMIT APPLICATION 426 W. Cedar•P.O. Box 186, Shelton,WA 98584 Shelton (360)427-9670 - Belfair(360) 275-4467 - Elma (360)482-5269 On the web www.co.rnason.wa.us APPLIC INFORM�ITION O N TIO Owner �/ Company Name Mailinn A Mailin Ad teasSkJ City to Zip C City fate Zip Code Phone Other Ph. D Phone Other Ph. Lien/Title Holder Contractor Reg. PINKI D Exp. Email address •AO E Mail Address Drivers Lie. 7 A DOB I.- -b3 Drivers Lic.# DOB SEPTIC f WATER SYSTEM INFORMATION -Connect to New Iptic Existing Septic X Connect to Water System Name of Water System We Sewer System Name of Sewer System, P R - 12 Digit Parcel No. Fire District Legal Description Site Address(PI incl tr et name, stre t u an city -mr. ✓ Dire n • 190=1� figpom 0 "WIT 017 Will timber be cut and sold in pbrcel preparation?Yes Is property within 200'of Saltwater —Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs 15% Is this mdt eubmitliat the result of a Stop Work Notice,Correction Notice or other enforcement action?Y TYPE OF JOB=New Add Alt Repair O r. PRIMARY RESIDENCE JM SEASONAL Use of Building- escribe Work f No. of Bedroom No. OfjBathrooms. d2—Square Footag - 1st Floor 2nd Floor 3rd Floor Basement Deck X—Covered Deck Other Sq. ft. ago Gara a Attached Detached Carport Attached -9- 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 gent on owners behalf,represents that the information provided is accurate and grants employees of Mason County access to the above scribed property and stnidure 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;INSPE INA TIVITYOF THIS PERMITAPPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICAMON. X Date: /Owners Representative/Contract (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department t4o' Environmental Health Department Fire Marshal 1111/6 9 ' f 4 FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing&Base Fee Plannin 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. � BUILDING PERMIT APPLICATION 01 426 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 INF �AATIO D Owner # �AG Company Name Homf Mailin ddr ss Y °r • Mailin Ad ress O City tnte Zip C d City f 5 Cr" State Zip Cod �� � e Phone � �1� Other Ph. ` -� G Phone bog Other Ph. Lien/Title Holder Contractor Reg.#W1 E hIQ Exp. E mail address it T L #-,,ai .CM4 E Mail Address Drivers Lic.# 1 J­F DOB to• 'to Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New �ptic Existing Septic Connect to Water System Name of Water System Welt X Sewer System X _ Name of Sewer Sys te LAI)l le 5 PARCEL INFORMATIQN -12 Digit Parcel Now Fire District Legal Description Site Address(Please,inclu tr et name, stye t umb ran city) r- )1 t AI✓ Directions o i e r M r l r - ill timber be cut and sold in parcel preparatibn Yes N Is property within 200'of Saltwater La River/Creek --Pond Wetland Seasonal Runoff Stream loes 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 Repair Other PRIMARY RESIDENCE SEASONAL Use of Building Describe Work 17vilainA 61,bl o. of Bedroom No. of-Bathrooms Square Footag - 1st Floor 5A _2nd Floor. 3rd Floor Basement 06A Deck X Covered Deck Other Sq. ft. Garage— Attached Detached Carport—A-- Attached -A— Detached MANUFACTURED HOME INFORMATION - Make Model ' Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Type of Heat Purchase Price$ Replacement Unit? Yeas/No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation. AckneWledgement 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 permittapplication 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 OFA PROGRESS INS PE TIO .INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPUCATION. X , : ; x 1 Date: f "D •.;Owner./Owners Representative/Contract (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department t-l-s C Planning Department 3 or t 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 MASON COUNTY PERMIT NO. _ t •% ;� 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 Aild 14 44 � ! <'�ti C Company Naive i '-4 Mailing Address , / ,sr° / f { - 1), 1 e - , /: Mailing Address City State I Ji_Zip Code fi�P4, F City ,�y #t`r' State Zip Code E Phone ' �" Other Ph. '` ^rrD Phone �• ' .. Other Ph. Contractor Re Lien/Title Ho der g• Exp. E mail address r4 tip' t I E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Sptic Existing Septic A Connect to Water System Name of Water System i .'t 17 Well Sewer System Name of Sewer Syste ' PARCEL INFORMATION - 12 Digit Parcel No. -4, a Fire District Legal Description • =i " Site Address(Please include street name, street number and city) LI'liziI ':t Directions to site 4 { ~ t ► r Will timber be cut and sold in p rcel preparation?Yes Is property within 200'of Saltwater La 'River/Creek 'ond Wetland Seasonal Runoff Stream Slopes or Bluffs 15% Is this permitsubmittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yeow TYPE OF JOB - New__,)(_Add Alt Repair O her PRIMARY RESIDENCE SEASONAL ❑ of Uoeof Bedroom, �,, No. of Bathrooms _2 Square Foota - 1st Floor'Building-�--1,1"/ c g —2nd Floor 3rd Floor Basement J6,16 Deck X Covered Deck Other Sq. ft. a Garage Attached Detached Carport—�K— Attached A— 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 permittapplication 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 INSPECTION.INACTIVITY OF THIS PERMITAPPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION. C X . f Date: Owner/Owners Representative/Contract (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department i Planning Department Environmental Health Department <fccj 4 for- Fire Marshal t dz 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 I State Fee Violation Fee Pre-Paid at Submittal Valuation$ TOTAL FEES MASON COUNTY PERMIT NO. I BUILDING PERMIT APPLICATION vt4 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 L. Company Name O Mailin ddr s Mailin Address j City tate� Zip C de City S State Zip Code Phone Other Ph. 3 -5 D Phone Other Ph. Lien/Title Holder Contractor Reg. t Exp. e.E mail addre=g2jlk? ► QD . COIN E Mail Address Drivers Lic.# DOB -(rid Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New �ptic ,, Existing Septic )C Connect to Water System Name of Water System Well Sewer Systern.,X_ Name of Sewer Sys em 12tAM r 5y tenii PARCEL INFORMATIQN - 12 Digit Parcel N O Fire District Legal Description Site Address(Pleasi inclu str et name, street numb rand city) A&r- ✓ Directions o s'a r+Lt n s-A 7e - i ta& AIA I fe an"16 0 Will—timber be cut and sold in p rcel preparati n s r Is property within 200'of Saltwater # Elder/-treek Pond Wetland, Seasonal Runoff Stream Slopes or Bluffs 15°l0 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 Otn r• PRIMARY RESIDENCE JR SEASONAL Use of Building Describe Work r + BedrooIs Q 34 No. of Bathrooms_Square Footag 1st Floor 2nd Floor 3rd Floor Basement —Deck—XCovered Deck----.;--Other Sq. ft. Garage Attached Detached Carport )�_ Attached ,A Detached MANUFACTURED HOME INFORMATION -Make Model ` Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Type of Heat Purchase Price$ Replacement Unit? Yeas/No Installer Name Certification No. OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation. AcknoWledgiement 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 OFA PROGRESS INSPE KIPN.INACTIVITY OF THIS PERMITAPPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X C tic %lr;- Date: - 1 g-OS (PWner Owners Representative/Contract (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department 5-Ii Planning Department 0 1 0, Environmental Health Department Fire Marshal 1 G q 2 - FEES Building Permit Pee 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$ Lk.(*f TOTAL FEES � R 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-�670•Belfair 360)275-4467•Elma(360)482-5269 n the weDD co.mason.wa.us APPLIC INFO Mf►TIO CONTRACTOR IMF, N Owner '' A01V Company Name Mailing, CA me-F res Mailing Address Citytate Zip C e City Mate Zip Code Phone Other Ph Phone Other Ph. Lien/Title Holder Contractor Reg.!* Exp. E mail address A- " - effif E Mail Address Drivers Lic.# 1 L DOB *' Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septi Connect to Sewer System Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel I Fire District Legal Description ' Site Address (Please includ tr et name, s1r and 'ty) Directions r j2n 9 ' L Is rope within 200'of Saltwa r Lake River/Creek Pond Wetland Seasonal Runoff-Stream-Slopes or Bluffs 1 15% TYPE OF JOB - New X Add_Alt Repair Other Use of Building Location of Fixtures/Units- 1st Floor X 2nd Floor_ Basement_ Gars a Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No.Qf Fixtures Fees Fuel Type:Electric.-,X- LPG_ Natural Gas_ Heat Pump_ Toilets Tyne of Unit No.of Units Fees Bathroom Sink Furnace Bath Tubs Heatpumps _y Showers Spot Vent Fan Water Heater Propane Tank Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PeletStove Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OVVNER/BUL.DER Admowledges submission of inaccurate information may result in a stop work order or permit revocation.Ado Medgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that t ant a "Ided 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 holier or any other party in interest regarding this application or the work proposed in the app1 P IN, I haws obtained permission from them to apply for this pemmlt and conduct dw work proposed. The owner or agent on owners behaN, epreserMs that the information provided is accurate and grants of Mason Courtly access to the above described property and structure for review and inspection. PFi00 TION Y OF A PROGRESS INSPECTION. X I Date: /Owners Representative/Contra (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 Group.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 Look Up a Contractor,Electrician or Plumber License Detail Page 1 of 3 Topic Index Contact Info Find a Law or Rule Get a Form or Publication Look Up a Contractor, Electrician or Plumber Printer Friendty Version General/Specialty Contractor A business registered as a construction contractor with I-Ed to perform construction work within the scope of its specialty. A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance. License Information License WIENSLHO990D Licensee Name WIENS LOG HOMES INC Licensee Type CONSTRUCTION CONTRACTOR 601315422 Verify Workers Comp Premium UBI Status Ind. Ins. Account 50275201 Id Business Type CORPORATION Address 1 18501 LOGANBERRY ST SW Address 2 City ROCHESTER County THURSTON State WA Zip 98579 Phone 3602738624 Status ACTIVE Specialty 1 GENERAL Specialty 2 UNUSED Effective Date 9/4/1991 Expiration Date 6/9/2007 Suspend Date Separation Date Parent Company Previous License WIENSLH1210A Next License Associated License https:Hfortress.wa.gov/lni/bbip/Detail.aspx?License=WIENSLHO990D 9/20/2005 Mason County Permit Assistance Center l Planning Intake Checklist Owners Name: Vol r Date: Project: Reviewed By: Commercial Developme uL Comments: Planner: GBM T CM SNG BJR Site Plan: North Arrow - el� Property Dimensions: X 4,16 P L JeC Streets and Driveways Shown.Road name: .l�.S'�i cgs 1 61 All Existing Structures shown with setbacks Well Location,Septic and Drain-field Shown backs Identify all surface water(streams,pon oreline, etlands,etc.) -d--Topography(sly) Proposed Structure Setbacks(Direction/Setback): _ F: _/ 'R• �,/ / 6 0 S 1•-s / S S2: r Utility and Drainage Easements: Yes o if yes enter condition#5 �1f- ,L �-Other Easements mf--Accessory Appurtenances ❑ County Access Permit Needed(add condition#0010) 4 ❑ State:Access Permit Needed(add condition#0020) C 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? (dogsigates) Shoreline and Planning Info Setbacks: Shoreline: Slope: Shoreline Designation: Comprehensive Plan: Rural Zoning: ❑ Not Applicable ❑ Agricultural 'RR 2.5(�D 20 ��Urban ❑ In holding 0 AW L/ 0 Rural 0 LTCFL ❑ RC 1 2 3 ❑ Conservancy 0�1 ❑ RI ❑ Natural ❑ RAC 0 RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT ❑ Urban Growth Area ❑ WR 0 Unknown 0 Unknown Water Body(t e of water if unnamed): SEPA: N Cm No nknown�� Flood Plain: YES N(C Aquifer Recharge: YES NO U own Map# Tags/Cases: _ RLC/SPI Case:- _ 6-Year Dev.Moratorium: YES O Eagle Nest Tag: YES NO Other YES O Addressing: Check box if needed ❑ eviewed by: Revised:07-12-2005 MPLANNING\CHARELL&RENEMPLANNING INTAKE MASON COUNTY RESIDENTIAL PLANS SUBMITTAL CHECKLIST Owner's Name: � _ Oc-) t Date: 1 Reviewed By: Documents: - -Building Permit Application Completed —Planning Intake Checklist Completed, —Site plan includes:Allowable building area,roof oved"b,'*cksAi4Q&.R' sT. _Fire Apparatus Access Road info required? Yes/No Energy Code Application Form-O Electric wall heater O Electric central furnace O LPG Furnace Heat pump with electric furnace O Heat pump with LPG furnace O Boiler(heat type__________) O Other:Specify: -x Mechanica/Plumbing lication-WATER HEATER FUEL TYPE Engineering? Ye No Snow load used: rcle one): _Geotechnical report or assessment? 10%W Construction Plans: -t 3 COMPLETE SETS ?-Plans Legible '�K Recognized Scale K Elevation Views �_Cross Section Foundation Plan -W Roof Framing Plan Floor Plan-Use of Rooms Noted Floor Framing Plan-all floor levels represented? Loft,crawlspace,etc. Deck Framing Plan,including covered.porch framing Plan Details: �c Roof framing details,truss lay-out may be needed JK Wall Framing-Does bearing-wall height exceed 10'?(Engineering maybe required) \Oct-/AA h Floor framing: Floor joists: bc^,<— ,Floor beams: Window headers: Typical header: Foundation:footing size,reinforcement Concrete Walls-Does Concrete Wall Height Exceed'9'?(Engineering may be required) ?< Landings at all exits? Less than 30"above.grade? Y /0 I Heated By Furnace-Location of Furnace � — Fireplace/Stove Information Shown-Fuel Type? _W'Window Sizes Marked on Plans 2-Story Garage? (Engineering maybe required) R602.10.1, 1't story of a two-story D145%,D2—55% Braced wall panels(shear walls)marked on plans or lateral engineering? (Plans may not be approved if not provided.) COMMENTS: IRREGULAR BUILDINGS(Irregular Shape)R301.2.2.2.2 Irregular portions of structures shall be designed in accordance with accepted engineering practice. A portion of a building shall be considered to be irregular when one or more of the following conditions occur: 1)Exterior braced wall line or BWP cantilevered or offset by more than 4' 2)Roof or floor is not laterally supported on all edges 2A)Portion of roof or floor extend more than 6 ft.beyond the braced wall line. 3)End of BWP extends more than 1 ft.over an opening more than 8 ft in width below. 4)Opening in a floor or roof exceed the lesser of 12 ft.or 50%of the least floor or roof dimension. 5)Portions of floor level are offset vertically 6)Shear wall lines do not occur in two perpendicular directions. 7)When a story above grade is includes masonry or concrete construction(exc:fireplaces,chimneys,and veneer). When this'applies the entire story shall be designed.In accordance with accepted engineering practice. 2003 IRC Plans submittal checklist simplified/WORD i y, MEMO NOMEMENNM ON M� MEN S ■ENEENSEMEONE ■ IMIN aoMOMS MENEM IMMEME ' ��ne AMEN 11 rsIs ��� NORLILVIN OMEN Wo' MORE RA NEW IF ,. rum MEMISM no EMEDEMEM ENO NNEEMWIIKMrMTM"vIM'W"6 OEM TOPOGRAPHYPROF - t+ IT - • • • Building number pproval:for offlat use Owner/Applicant: :.• r i. Env. Health: ,� 1 . S� �. a ` � �+ :; !, - _ — -� -� -,-- G � ', �,, �, `ice -o �_ � p L � �� '�'� _ ,� � Z- f 6' r-- -- I i i t �` {E i 1 1 r fi� ,,,�" r E � l { a f s i DECK_ PZoFbl�c i 1 j 1 1 1 � j dC k"" MASON COUNTYAM ' V DEPARTMENT OF HEALTH SERVICES 9 2005 Environmental Health C�JAR ST. Personal Health "IttuNIWENTA L PO BOX 1668 SHE LTON,WA 9858 HEALTH LOCAL(M)427-967 BELFAIR(WO)275-446 Application for Determination of Adequacy FAX(WO)427-779 Instructions PART 1: ApplicantiParcel Identification e- Name of Applicant 11m Li!5A DGVIL _ Date Mailing Address"L_M &ArC'"k-Ik b Telephone (3 75-'/097 Assessor's Parcel Number 1;J#5 LJ 40a Type of Water System Check One): Reason for Applicadon fCheck One): ❑ Public/Community Water System(2 or more Building permit COnwdlOnsr* ❑ Land use application, if so.. Individual water source(one connection), ❑ Division of land: if so.. Well #of Parcels? SPH ❑ Spring/surface water ❑ Other(explain) ❑ Boundary line adjustment ** If you have more than one maldence ❑ Other ex lain ( P ) connected to this well, check the Public box. PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water S stem Name ot Water System Water Facility Inventory (WFI) Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ❑ 1 am the manager of this water system. The water system has been approved for services. There are presently connections in use. This will be the confiRlion. This water system is able a�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 Manager Date H..IWELLIWEB srrmwATERADI.Doc Update:August 2oo5 Individual Water Well Water-well report(attach to application)Depth �J� ft. Well capacity test(attach to application) ( gpm apd . Constructed Results from tests ar+er noted on the wager w� Results ltWeil capacRy St Me 59 Me wellan these tests'wN be aac apted. ff ft have ter waif report.cenrWt be located applicant or if the**or well capac y test;a well test, pr»vidw staWmahm of da w- down data n►trst be a lkensed contractor. Satisfactory bacteriological test(attach to application) individual-S do urface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection ❑ 1 have reason to believe that this water source can provide at least @W ggallons ppeerr day and/or provides water at a rate of 2 gallons per minute based on the following observatiortS. 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. 004* ' y '4 c t x © I S F > K•IWELLIWEB STMWATERADf.DOC Update:August 2005 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT WSEC/VIAQ Compliance Application Owner: ♦ G T p n - 097 Parcel#: Type of project 00 New Residence ( )Addition ( ) Remodel Total Sq. Ft. i StFloo : - 25,flo �� Heated Basement: of heated area:: (l�7 Heating System Type: O Electric wall heater O Electric Central Furnace O LPG Furnace Heat Pump with electric furnace O He t pump with gas furnace O Boiler,specify fuel type: Other: S eci Glazing Prescriptive Option see reverse side circle one: I III Percentage: Compliance Method' O Component Performance , Chapter 5- calculation worksheets required Check one:: O Systems analysis, Chapter 4 O Whole House Ventilation system . O Whole House Ventilation using a Heat Ventilation using exhaust fans&window or wail fresh air Recovery Ventilation System (VIAQ 303.4.4) System vents (VIAQ 363.4.1) Check one 4F 'Whole House Ventilation Integrated O Whole House Ventilation using an inline with a Forced Air System (VIAQ 303.4.2) . supply fan. VIAQ 303.4.3) Window & Door Schedule (if needed, attach an additional sheet) Total Manufacturer Room/location U-Factor Size Quantity Square Feet Windows: ter : +-eye s-r'X�1`-e Ta P z V Ica:w�P-e.I&- -C f- 3 ` 1'' Z v, :k�Q.--R-, it Zr 4cZ e<-6__ lit &rfi-, s :!()r 6 ce�-ka, e k C-` ,2 mo.& a60W% e.— c^ �� �� �l J Cal•- `:k�e�� �ic�.: YXT '-1 Y3 /2— �. b. e-e- L rvi —ba w�ew f9' 7 X Z 7D Windows: Total Sq. ft. �s-( — Doors: icy_ �ea�• (_' � -cy6eNoNy /x16..Kj�` 2. CYO Doors: Total Sq. Ft Total window and door areal 3 y/,S Total window &door area 3�//S /(divided by) total sq.ft of heated area /(o = /3+6 %of glazing MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Permit Assistance Center SHELTON(360)427-9670 ' BELFAIR(360)275-4467 Elma (360)482-5269 FAx: (360)42.7-7798 WEB SITE: www.co.mason.wa.us P.O. Box 186, SHELTON 98584 2003 Washington State Energy Code (WSEC) 2003 Ventilation and Indoor Air Quality Code (VIAQ) effective July 1, 2004 Code Compliance Application Form The following information will be required for the WSEC and VIAQ plan review: 1. Complete the Washington State Energy Code/Ventilation and Indoor Air Quality Code (WSEC/VIAQ)application located on the reverse side. 2. Complete the window and door schedule on the reverse side. Include all windows, skylights, sliding glass doors, french doors and any door that is more than 50% glass. Use rough opening dimensions of the windows and doors. Information about the U-factor of the window will also help to expedite the energy code review. If you are complying with the WSEC by prescriptive path and are using the area weighted average method you must include your calculations. 3. On your building plans note the location and fuel type of water heater, location of exhaust fans (bathroom, laundry, kitchen, etc.) and R-factor of insulation proposed for walls, floors, ceilings and slabs, 4. Questions? Call Mason County Community Development at (360) 427-9670 ext. 284: Additional WSEC and VIAQ compliance information is available on the internet at : http://Www.energy.wsu.edu/code/ Prescriptive Requirements "for Group R Occupancy Climate Zone 1, Table 6-1 Glazing Glazing U-factor Door Wall wall Wall Area%of Ceiling Vaulted Above interior4 exterior Option U- z s Slab' Floor Vertical Overhead�� Factors Ceiling Grade below a Below 12 Floors on grade Grade Grade 1' 12% .35 .58 .20 R-38 R-30 R-15 R-15 R-10 R-30 R-10 15%* .40 .58 .20 R-38 R-30 R-21 R-21 R-10 R-30 R-10 Unlimited Single Family Res .40 •58 .20 R-38 R-30 R-21 R-21 R-10 R-30 R-10 (R-3)Only *Reference Case/Call(360)427-9670 ext.284 for footnote information. Log&solid timber wall with a min.avg.thickness of 3.5"are exempt from the above grade wall insulation requirements. m �o o °: mn�i � < � o � v CD 3 cnm Ln ? 3 O d S N ? y < CD < TI 0 r CD � CD p (D � g c w o k � -� m (n c = n N M. 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