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Box 186, Shelton,WA 98584 427-9670h4800-562-5628 PLEASE PRINT -i t #1 Owner mas'c 7o (69.6 M Rwtr,� Phone-*',,(C200 89,9-09 71-- Site Address Pare District# City St_VA Zip Directions to Job site QLa BEt.FAgIQ lA u/i 'T}- t MOST ON 014311114-ITO IMNA"A 12jr.14T 05 j 1M I Z6' Owner Mailing Address me- 4tu, Dr-, 'R 4 City R.T St Zip°I Liery Tdie Holder 1-00 Address V O. 13aK Z©C I City �-�% L jR St_ zip �l$6L� #2 Contractor Name N le- C g!r OW ) Contractor Reg# Address Expiration Date City _ SL-� -- Zip _ Phone# #3 If septic is located on project site, include records. Connect to Septic?__X _Public Water Supply Well Connect to Sewer System? Name of System (if residential, proof of potable water is required) #4 Parcel No. 12-SQq-�ri___1 - 0907— Legal Description 59 QQP,✓ #5 Building Square Footage: (existing/proposed) '� C7Ti� " T - a 1 st FIB/ 2nd FI / 3rd FI / Loft / Basement / Deck / I2O #bedrooms #bathrooms_L/ Garage_/ Carport(/ (Circle:Attached or Detached?) Other sq.ft. - #6 Use of building PRIVA-W Describe work PISTb-mil. ON 2t'1'>rf ( swo MO glLy #7 Type of Job: New _Add Alt Repair Other #8 OMOBILE/MANUFACTURED HOME INFORMATION Model Year MOO Make-RM!b�ei -1 Length+_Width14 Serial No. #Bedrooms _#Bathrooms_ Type of Heat % tJZ1=CR1G rVIRAWc - Purchase Price$ 1001 x9•dw #9 Indicate by circling the applicable source if any water is on or adjacent to subject property: River Pond Creek Stream Wetland Marsh Saltwater Seasonal Runoff Other Show f 6 116j,W1111no on the site plan I Lot Dimensions 'f 1ood Zones t Existing 3trt�ctures`. Fences Structure Setbacks ` Driveways v Water Lines+, Shorelines v Drainage Mail.�� Topography&, SePtic..�yrstems�..y ` ' '� iVetls c1 �' ��t� %'�✓ ; Ct Proposed improvements Easements Name of'ankkV StreetA\ r Indicate Directional by {N, S �; W)` - in relation to plot plan APPLICANT TGIUFA�S61 its brZ'TD.C}�E'D APPLICANT TO DRAWfi0P0GMPKtP1 ILE-BELL* yW Toro ON 4n 5rrr PLAWV �1 3.It8a'�! '•���; ��� SIC Plumbing Fixtures($3 each) egg <Mar�ical Fixtures(16 each) `No.—LToilets CIRCLE FUEL TYPE: Gas, Electric, / Bath Basins Heatpump, Other 1 Bath Tubs _Showers Furn BTU / Hot Water Htr - _ Heatpumps _Laundry Washer _ Vent Systems Sinks Spot Vent Fans _Floor Drains Ng,, Boilers/Compressors _Laundry Basins _ HP —LDishwasher No., Air Handling-Units _Disposal cfm# _Urinals Ng,, Fire Protection Systems _Other _ Auto. Fire Alarm Sys 50.00 Fixed Fire Supp. Sys 5Q0 Permit Basic Fee 15.00 _ Auto Fire Sprink Sys 25.00 TOTAL PLUMBING $ Jy4, Other Gas Outlets Wood, Gas, Pellet Stove NOTICE: TIME-PERMIT BECOMES NULL AND VON) IF WORK OR CONSTRUCTM AU'T#0R9WJS T COM- MENCED VATHIH 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee 15.00 WORK IS SUSPENDED OR,ABANDOWD FOR A PERM OF 180 DAYS AT ANY TilM"AF M WOFK-0 COM TOTAL MECHANICAL S MENCED-PROOF OPCONTINUATMOF WORK IS BY MEANS OF A 131RO(MW INACTION: OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT - I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I_AM-A CURRENTLY REGISTERED MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I RCW 18.27, AND AM AWARE OF THE MASON COUNTY AMAWAREOFTHEORDINANCEREQUIREMENTSREGU- ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATNGTHEWORKFORWHICHTHE PERMIT ISISSUED MIT IS ISSUED AND THAT ALL WORK DONE,MLL BE IN AND-ALL WORK DONE-WILL-BE IN CONFORMANCE CONFORMANCETHEREWITH.NO CHANGES SHALL BE THEREWITH.NO CHANGES-SHALL BE MADE WITHOUT MADF� WITHOI-T FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING THE BUILDING` EPARTMENT. DEPARTMENT. X OWNER X BY. DATE DATE , DEPARTMENTAL REVIEW F61 OFFICE USE ONLY Appmed cord. Hold AW*W Planning: ' Gi 100 Environmental Health: Building Plan Review M F 6. Ver_, . Mjf L tntprn/ , AT-/&AP, po&7- AtP 2esf LAJ OccupanckGroup: R 3 m Type.of Const: C11, lei Fire Marshal: q Other: Special Conditions: FEES- Building Permit Plan Check Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection ''�:'�*� i :'1�3�;�3 Building State Fee . Other Other Building Valuation: /, /SZ. TOTAL FEE 13� � � f 11 1 6 // ' a •e ,� 41 L � I r� MA AUNTY lEP NT of GENERAL SERVICES =Cmpty mg.III 426 W.cedar P.O. 1$6 Shelton.Wwhmwon 9&W f;3+6Q 427-%70 BUILDING PARKS&RECREATION FAIR/CONVENTION CENTER ADMINISTRATION March 6, 1995 RE: Permit # Dear mg On - (D/29/qLl , this office approved for issuance the above permit number. Pursuant to the Uniform Building Code, Section 304, this permit, once approved for issuance, must be issued within 180 days to stay valid. Failure to pick up the permit within the 180 day time frame will void the permit and it will be necessary for you to re-apply for the permit thus, meeting all new review requirements. Further, the Uniform Building Code, section 304 allows for the collection of the plan review fee if a plan review has been performed and the permit cancelled. In the event that you no longer require the permit or choose to cancel the Permit, the plan review tee due on this permit is $ The check or money order should be made payable to the Mason County Treasurer and submitted to this department for processing. Once the plan review fee is paid, we will return the plans to you and cancel the permit request. If you wish to obtain your permit now, the amount due for your building permit is $ N'') Co. Once received, we will issue the permit, either in the office or we can process the issuance through the mail. -The permit will remain valid for a period of 180 days. At the end of this 180 days, an inspection will be required or a one-time only extension can be granted through letter request however, all future extensions must be granted by progress inspections. Please respond to this notification prior to April 7, 1995. ncere Cheryl R gan Buildin De pa ent (206)427-9670 CC: Property File TIABOpf COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX--1666 SHELTON, WA 9859$ (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 09/O1/92 INSTRUCTIONS 1. Complete Part 1. No determination can be made until Part I is fully completed. 2. Complete only the portion of Part 2 applying to the type of water "system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANTMARCEL IDENTIFICATION !€#ifit#i#!ti#€Ei#!t€#t€iti#€itilti#i#liliiltiit##itittli€!itttiiiitiHiii€ii#iiltlii#lttiltilt#tits€t€1liitEiltltitiNt€#i#ititiittiili€€i#ti!#iNIItI!#!it!#litRit#iii#HI# NAME OF APPLICANT [2MAWAM Q IA((, DATE o'•Z4,'1 3 MAILING ADDRESS 05ZI M to 141L.L J9Z, A& TELEPHONE (20(o) $JF-L-90�- City ntmt• zs.n ASSESSOR'S PARCEL NUMBER 2 3O 910 Z S SUBDIVISION (If Applicable) Howe-u Sp T „g►Q (,�. �, ZzOT SQ TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) . Public/Community Water System ® Building Permit, Single Family Res MV LAJ Individual System, Drilled Well ❑ Building Permit, Commercial El Individual System, Dug Well ❑ Building Permit, Replace/Remodel Individual System, Spring Land Use Application ❑ Name Individual System, Surface Water Type Individual System, Other ❑ Other PART 2-A: PUBLIC WATER SYSTEM - EEEtilEl[1ElltllE!€tE!ltitttHEttlNttttttt#EtttHtittli(1lItiElEltifi!!!!llElillEE!!!0!lEiE!!illtEEitillElE!litttlElittill10lEtElitiil#itit!!E#IlitllllElllEiitt#i#t!!!it#1 NAME OF WATER SYSTEM WFI ID The water purveyor for this system-etas previously filed a certificate of water adequacy with the health district. I as er o!manager the above referenced water sy stem. The water system has DOH approval for service connections, with connections presently in use. The applicant has approval to connect to this water system. Service of water to the applicant for domestic purposes is consistent with both the water systm plan;and the water right permit presently in effect. water lines are available to the applicant's property line, or the applicant has made satisfactory arrangements to extend the lines. SIGNLUlT M OF SY&M MA8AMM DMT8 PART 2-B: INDIVIDUAL (YELL iill!!1litllltllltltillllllil!lilitil11111lItliilittlliitlillliiiilil!!lliiillliliillilillll 11111111 ill Iiliillilllilllillfliililill!lllNiiiliililill WELL DEPTH Ft WELL CAPACITY Gallons/Minute GallonE/0.1, El Well log is attached to this application t Well capacity test results are attached to this application , NOTES: Well capacity tests are often performed by the well driller at the time the well is con- structed. Test results from these tests are noted on the well log. Results from these tests will be accepted by the health department. If a well log cannot be located by the applicant, a Well capacity test must be performed by a licensed contractor. Baler or pump tests are acceptable, provided stabilization of draw-down has been measured and recorded. Satisfactory total coliform test is attached to this application. PART 2-C: IrHYM'DUAL SPRING OR SURFACE*ATE. l li3t731:E� :;51llili#€.tiil#Ilitiil #I-iill#Illiilti##iii#ii#I#i##1#1#i#Ililillllllllliilltlliiiitl#€#�#}11##t##i�i111#I.:IJi�#��it;#####�l'#;llifil##tii###1##I##t##€####1#1## El WDOE permit is attached to this application I have reaVAM.%tb,.be1B.We the spring ' proposed as-'t')l `water source will supply adequate water its intended purpose. This belief is based on the following observations: , { • f AUTHOR OF STATEMENT DATE 1 RELATIONSHIP TO APPLICANT NOTE: In addition to providing the above statement, the applicant will need to arrange an on-site inspection by the health district prior to determination of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use. Iltlllllltll#11l#It111'slliitllilIliltii111lll III IIII#III IIItilll!III IIIillililil111111111111111111 fill III IfIIII#IIII#IlitI1111I1iili11 III IIIIIIllil#111111111t1i1lllllli#!!1#! SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. Note: This determination does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regu- lations. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade- quate to meet needs of its intended use for the following. reason(s) : HEALTH INSPECTOR .�1@�._� �J DATE 5- RWJi 114 09/01/92