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BLD2009-00299 Final SFR - BLD Permit / Conditions - 10/20/2010
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(� By Date /!� -��' ��' Pass or Request Inspect. c Type of Insp. Fail Date Date Done By Comments m 7,/ O - FJr CD pwv 8 F iL VA4. - 0 5 S 1 D�S/ice <fiG' - C1/L o-z-e Z- T S It 0 t boy Nt- L-A�<,C- ,e�Q o 73 I I lk I� o > I cl b P I 1A 301 PLANNING: W a4�ed@d �r L SETBACKS ARE MEASURED FRONT THE FURTHEST OJECTION OF THE BUILDINCa ? �, I E: cn A = mo { cn z cc PIANN44(m iI N o -i p p d 8 C) t O ae t OM i Al ,� ozz O � I-AKt F-P1c KSotJ Fox Custom Homes, Inc. Phone: 253-858-2614 Fare 253-858-6221 Job Name: Site Address: 2 Y `d Map H'j"q �b Directions: II I w "T ke S&MA fkit LE4 +-o a+d Yz ( �+ l -� �- 01 IE Old f),Atf;Oij"v, K (171, athrlov f- o N E -eq✓ CYee� D�w4 ; fo4�U+ a wNi tl -a e Ot r igvtt- cw+o La�C,ev CLO, . V1(j jp - 10 t s Gvt rr11 g h r -fir oY rru cave a �rY g @� lio vw 4 t&f A Yi ov duo wAx*0 fcv( i Look Up a Contractor, Electrician, Plumber or Elevator Professional License Detail Page 2 of 3 Type Parent Company a Other Associated Licenses License Name Type Specialty Specialty Eft 1 2 SUNCO CONSTRUCTION E N SUNCODLO42DM DEVELOPMENT CONTRACTOR GENERAL UNUSED 3/1 LLC SUNCO CONSTRUCTION SUNCODC0651)1 DEVELOPMENT CONTRACTOR GENERAL UNUSED 3/2 CO FOXHOL*015PL FOX HOMES CONSTRUCTION GENERAL UNUSED 10/ LLC CONTRACTOR 2 Business Owner Information 2 Hide All Name Role Effective Expiration Date Date MCALEENAN, MICHAEL AGENT 07/18/2007 E COCHRAN, BRIAN PRESIDENT 07/18/2007 COCHRAN, MASAKO VICE 07/18/2007 PRESIDENT Bond Information Bond Bond Effective Expiration Cancel Impaired Bond Company Account Date Date Date Date A Name Number Until 1 DEVELOPERS 746792C 05/15/2007 $1, SURETY 8t Cancelled https://fortress.wa.gov/lni/bbip/Detail.aspx 4/22/2009 Look Up a Contractor, Electrician, Plumber or Elevator Professional License Detail Page 3 of 3 JINDEM CO s Insurance Information Insurance Company Policy Effective Expiration Cancellml Name Number Date Date Date 1 2 B ROO KWOO D WAC460315 06/2 5/2008 06/2 5/2009 INS CO 1 BROOKWOOD WAC460315 06/2 5/2007 06/2 5/2008 INS CO , 'r access About L&I I Find a job at L&I ( Site Feedback I Toll-free Numbers AkMAt' m ®Washington State Dept.of Labor and Industries.Use of this site is subject to the laws of the state of W ski!kt���Eivaartn5�nt itch..�Hx AccenAg[€€meot I Privacy intended_use/external content Mlicy I Staff, I i https://fortress.wa.gov/lni/bbip/Detail.aspx 4/22/2009 MASON COUNTY PLANNING DEPARTMENT FAX Phone:(360)427-9670 ext. Fax:(360)427-8425 I TO: Fo,< limesCOMPANY NAME: CONTACT NAME:26` t� FAX NUMBER: �) � ZZ PHONE NUMBER: SENDER: A qedojfc- assEs5w4d REGARDING: BLS pa4e� ee� 64wS14 ��pe-f , p Number of Pages (Include Cover Sheet): , Date Sent: 5f-7 IC Time Sent: SS MASON COUNTY DEPARTMENT OF HEALTH SERVICES April 29, 2009 PO BOX 1666 Shelton WA98584 Shelton (360)427-9670 Fax (360)427-8442 JERRY SHANK Elma (360)482-5269 2304 N ANDERSON ST TACOMA WA 98406 Belfair (360)275-4467 Case No.: BLD2009-00299 Parcel No.:223047690110 Dear Applicant: Your building permit will not be approved by Mason County Public Health until the following items are completed and received in our office. 13 Application for water adequacy completed and signed by the water system manager. Please call me at(360)427-9670, ext. 279 if you have any questions. Sincerely, Amanda Reynolds Environmental Health Mason County Health Services Comments: 4/29/2009 1 of 1 BLD2009-00299 ACCESS & GRADE INSPECTION PERMIT #: C2-c:z�>L� ADDRESS 2- ro Lf% r`j /��- r INSPECTOR DATE: DRIVEWAY ACCESS Length: Width: Surface: Size of turn-around: Condition of shoulders: Vertical clearance: need post at end of driveway with reflective address numbers GRADE,OF DRIVEWAY %. OF ROAD % ROAD ACCESS Length: Width: Surface: .Condition of shoulders: Vertical clearance: ( ) BURN PERMIT REQUIRED FOR LAND CLEARING FIRE. ( ) LOT INSIDE SMZ, 4X4 FIRES ONLY. ( ) LOT INSIDE UGA, NO OUTDOOR BURNING PERMITTED. LOT TOO SMALL FOR: BURN PERMITS 4X4 FIRES. REMARKS 'C--5 (continue remarks on back) NameshA YL.e— Parcel# of o� '-1 �? • �"I 11() BLD# Mason County Department of Community Development Small Parcel Stormwater Management Application/Worksheet (page 1 of 2) Per Mason County Code,Title 14,Chapter 14.48 a stormwater site plan is required whenever a building application is made for residential development,or redevelopment',with more than 2,000 square feet of impervious surface'. 'Redevelopment means,on an already developed site,the creation or addition of impervious surfaces,structural development including construction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment. 'Common impervious surfaces include,but are not limited to,rooftops,walkways,patios,driveways,parking lots or storage areas, concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces. Surface Type Length X Width = Area *All dimensions in feet Buildings X = �, X = �q Measurements for buildings are taken at the X _ y3 perimeter of the farthest projections(example: eaves/gutters) X = Driveways X = X = Length of drive begins at the right of way X = Parking Areas X = X = Any paved, gravel or packed area per definition above table X = Patios/Walks X = X = Any paved, gravel or packed area per definition X = above table Others X = X = � .. x If the Total Impervious Surface Area is LESS THAN 2000 Square Feet, please read,acknowledge and sign below. Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity. Owner/Builder/Agent Acknowledges that 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,owner's legal representative,or the contractor.I further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- described property for review and inspection as may be required. X Owner/Agent/Contractor(circle one)Date: If the Total Impervious Surface Area is GREATER THAN 2000 Square Feet,please read,acknowledge and sign the information provided on page 2 of 2. i Page 1 of 2 1 Name Parcel# BLD# Mason County Department of Community Development Small Parcel Stormwater Management Application/Worksheet (page 2 of 2) Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity. Title 14,Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater Management in this jurisdiction.A complete copy of the ordinance can be found on the Mason County website: httl2//www.co.mason.wa—us/code/Commissioners/index.htm Please follow the links to"Title 14,Chapter 14.48 Stormwater Management". Regulated activities shall be conducted only after Mason County Public Works approves a Stormwater site plan (Mason County Code Title 14 Chapter 14.48 section 14.48.70). You will receive a copy of the Public Works document entitled "Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan".This document will assist you in preparing the necessary information and plans for Public Works to review and approve. Per Department of Public Works this document will constitute an approved plan if all of the relevant details*are to be installed in their entirety AND no part of the stormwater system adversely affects any septic system (see Environmental Health information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval. A design by a registered professional may be required for more complex sites. *These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan on the pages that begin with"Handout" PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE A)X The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed in their entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel. I B) An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel. If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works Department can provide additional instructions,guidance and examples.(Section 14.48.130)contact Public works at: Phone: (360)-427-9670 EXT.450 Mail: P 0 Box 1850,Shelton WA 98584 Physical:415 N 6th St,Shelton WA 98584 If this development has,or will have,a septic/drainfield system you may need to contact Mason County Division of Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or any other, parcel. You may also wish to consult with the septic design professional involved with the project. Mason County Division of Environmental Health can be reached at: Phone:(360)-427-9670 EXT.352 Mail: P 0 Box 1666,Shelton WA 98584 Physical: 426 W Cedar St, Shelton WA 98584 A condition will be added to the building permit that states, in part,that all conditions the stormwater site plan will be met prior to a request for final inspection of the building permit. Owner/Builder/Agent Acknowledges that 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,owner's legal representative,or the contractor.I further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- described property for review and inspection as may be required. x !SZaµ-, Ko -75 GLG b • Owner/Agent/Contractor(circle one)Date: 2 — o Page 2 of 2 G I A t A it Alan Matscord Design Assoc.,Inc. Q B'^ 'i °� ' 41 1305 Northwest ltlth Avermc t Portland,Oregon 97209 + � `'ti PHONE(503)225-9161 A t F I(_!P # �-• FAX(503)225-0933 DtiSlGN ASSt7CtAT135, INC, "" November 24,2004 This is an agreement between you,the end user,(hereafter referred to m`you'),the design professional(hereafter referred to as"Agent")and Alan Mascord Design Associates,Inc.(hereafter referred to as-AMDA), By signing and returning this form.by mail or faaaimile,you indicate that you agree to be bound by all of the terms and conditions of this agmernunt. Please note that ALL SALES ARE MAL. "MULTIPLE-USE" LICENSE to use PLAN 1128E - VELLUMS AMDA grants you and your agent a non-exclusive license to modify the above named plan and related documentation(hereafter referred to as "dwigro for the construction of your,or your client's home,subject to the following terms and conditions: you audler your Amimt Mw • Modify this design to meet your needs,local codes,regulations and specific site conditions. • Provide this design,.in whole,to others(architects,engineers,draftsman,and others,herein referred to as "Agents")for the purpose of allowing them to modify the design to meet your nccda(your agents will,in turn,be bound by these same provisions). • Use this design,as altered by you(or your agents),for the sole purpaso of constructing one or molt.-S rlCttlres. You and/or v nr Agent May_N_ • Scll this design,or altered designs based upon this design. • Distribute this design in its original,or altorcd form,in any way,or on any media,except as necessary to complete alterations through your agents or,except as necessary to use this design to construct 2He or more strilctl W-",. • Imply that AMDA is responsible for the revisions to the design,as altered by you or your agent%. • For CAD files,remove the AMDA copyright or the logo block that identifies the design as a derivative of an AMDA stock plan For CAD files,remove or obscure the license number(invoice number)that is found on the design CAD files. • For CAD files,extract any portion of this information,from the context of the design,and apply to other projects,or distribute to others,any part or portion of the design. All symbols,graphic conventions,and collections of drawn entities contained within these drawings,representing the design,are considered a portion of the whole,and arc subject to all terms and conditions herein. 4WNERSIII.I'_ AMDA retains title to,ownership of,and all other proprietary rights in the original,and all subsequent copies of the design,and any part thereof,regardless of the form or media in which and on which the original and other copies may exist. Title,ownership,and all other proprietary rights in. with AMDA even if the design,or any part thereof,are modified by you or your agents,or arc included in altered designs created or modified by you or your agents. This license is not a sale. .ENERAL P V i NS In no event shall AMDA,or any entity under it's control,be liable for any part of this design as modified by your Agent.The Agent is responsible for adapting the original design to the requirements of you,your building site and any applicable codes and regulations. Failure to comply with any term or condition of this license agreement will automatically terminate this license and will make available to AMDA other legal remedies. This license agreement is the entire agreement between AMDA and both you and your Agent and supersedes any other communications or advertising with respect to this design and related documentation,if any provision of this license agreement is held to be invalid,the remainder of this agreement shall continue in full farce and effect. End User orr Design Pro(ecsr'onRl f4eenr MASAKO COCHRAN FOX HOMES,LLC 915-26TH NW SUITE C-2 GIG HARBOR,WA.98335 With my signature,1 do hereby agree to the above terms and conditions and indicate my understanding that ALL SALES ARE FINAL. CAI))File Format(please ebioose one) Sign Data [] AutoCAD 2004 []AutoCAD 2004 DXF (your . a _",r"here) ❑AatoCAD 2000 Q AutoCAD 2000 DXF ❑ AutoCAD R14 ❑ AutoCAD R12 DXF Signed I.ag"r htre) Date _ Reproducible Vellulms 's signort.re ❑ Reproducible Vellums MULT"K.UC In_P-W FOX CUSTOM HOMES , INC . FACSIMILE TRANSMITTAL SHEET FROM:FAX NUMBER: '7 DATE: COMPANY." TOTAL NO.OF FAqfS INCL. COVER: PHONE NUMBER: RE: ©URGENT El FOR REVIEW ❑PLEASE COMMENT 0 PLEASE REPLY d PLEASE RECYCLE NOTESICOMMENTS, +vw, ., i` 1 `J 4-vlese- Pavq<3 bv S &Lx- VV.,c C( Ve... J 'cyo, (uo 's {J C� l(S - ��; FOX HOMES LLC - 915 2eTN AVE NW, SrE, C-20 GIG HARBOR, WIC 08335 PHONE: (253) 658-2614 • FAX: (25s) 856-8221 Look Up a Contractor, Electrician, Plumber or Elevator Professional License Detail Page 1 of 3 Information in Spanish I Topic Index I Contact Info ( __ Home Safety Claims 8t Insurance Workplace Rights Trades&Licensing Find a Law(RCW)or Rule(WAC) Get a form or publication Return to List > Start a New Search > a Printer friendly General/Specialty Contractor A business registered as a construction contractor with LEtl 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. Business and Licensing Information Verify Workers' Comp Premium Check for Dept. of Revenue Account Status Name FOX CUSTOM UBI No. Jo602632253 HOMES INC Phone No. (253) 858-2614 Status ACTIVE Address 915 26TH AVE License No. FOXCUCH931 MQ NW STE C-2 Suite/Apt. License CONSTRUCTION Type CONTRACTOR City GIG HARBOR Effective 7/18/2007 Date State WA Expiration 7/18/2009 Date Zip 98335 Suspend Date County PIERCE Specialty 1 1� GENERAL Business Corporation Specialty 2 UNUSED https:Hfortress.wa.gov/lni/bbip/Detail.aspx 4/22/2009 /,g�.0200 9"'0029/ MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health - ` —''s" 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. Complete Part 1.; No determination can be made until Part'1 is fully completed.' ` 2. Complete only the portion of Part<2 applying to the type of water system utilized. 3. Submit 6ompletedapplication,with attachments to the health de 'artment for review. PART 1: Applicant/Parcel Identification Na,—,,.- cf Applicant SHAN� LnJQtC / ��r -0 Mailing Address 30fTelephone ;2S3 7 -9-<317 Assessor's Parcel Number 223 f 7b 0/f D Type of Water System Check One): Reason for Application Check One): if Public/Community Water System (2 or more K Building permit connections)" ❑ Land use application, if so.. ❑ Individual water source(one connection), ❑ Division of land: if so.. 0 Well #of Parcels? SPL - 0 Spring/surface water ❑ Boundary line adjustment ❑ Other(explain) ❑ 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 Water Facility Inventory ( 1) Number: t G c" (write"none"for two party) `L J I am the manager of t4is_1vater system. The water system has been a for services. There are presently I K 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 li is set b state and local regulation. Signature of Water System Manager Date I:IEN FORMSIWAT RAD4.DOC Update:April 2006 j I 223047500100 Z j 223047500070 I 223040060000 I Y 223042222222 1 223042000000 j U w I 223047500090 w 223047500080 I � ( 223047690010 j -� - -� 223047790160 2230477901601 223047690020 -1 223047690030 2230477901611223047790161( ::]' 223047690040 223047790150 2230477901501 223047690050 2230477J9900151 223047790151 223047690060 I / iI� 223047790152 223047790152 1 ,� I t- 223047690070 223047790140 223047790140 223042000000 1 1-1 223047690080 223047790141 223047790141 222 047690090 �----- �,. 223047790142 223047790142 223047690100 ' 223042222222` ._4 1 223047790130 223047690110 1 �_� 22304779013V 223047790131 223047690120 f ,� r' 223047790132 223047790132 T23NR2W I 223047690130 3 j- 22047790120� 223047790120 223044000000 223047690140 223047790121 223047790121 223047690150 223047790122 223047790122 2230477901101 1 w 223047690160 C) ' \ �223047790110 w 223047790111 , g 223047690170 i 10\-�230477 I2�I2 304779011I 1z 22304769018022304769019� 2230477901010 223047790101-� 223040060000----__ 1 / / I223047690202 223047690201 j 223047790092 223047790091 223090200010 223047690 01� ' 223090004000 L- � ( 223099999999 223090004000 N 1 inch =400 feet W E 1 inch = 0 miles S I Individual Water Well ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test(attach to application) gpm gpd The well driller often performs well capacity tests at the time the well is constructed. Results 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 by the applicant or if 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 by a licensed contractor. F Satisfactory bacteriological test(attach to application) Individual S rip /Surface Water JDOE perniit (attach to appliGduun) ❑ 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. PA Health Department Evaluation (Staff Use Only) SATISFACTORY DETERMINATION: Applicant's Water supply appears adequate' fo meet the needs of.;its intended use.. This deterriaination,does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely into the future, orguarantee compliance with' all applicable WDOE water resource regulations. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ` adequate to meet the needs of its intended use for the following reason (s): ' REVIEWER'S SIGNATURE DATE D 1:IEH FORMSIWATERAD4.DOC Update:April 2006 MASON COUNTY PERMIT NO. BUILDING PERMIT APPLICATION J41 1A r) 426 W. Cedar• P.O. Box 186, Shelton, WA 98584 Shelton (360) 427-9670• Belfair(360) 275-4467• Elma (360) 482-5269 � 5 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner 115 Company Name X /.USrD14 1104ys INCH Mailin Address O 0 Mailing Address 15 1& t!b NtN �� GZ City State W Zip Code n LP Cityal(4 HpQ(iOFZ State Zip Code Phone Other Ph. Phone 10- -Zyl ft Other Ph. Lien/Title Holder Contractor Reg. #OXCiVe,11 93 1 M Q Exp. E mail address-41n&rt K 2 �,nw•Gas'(•• hGt E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No 3 0 1 t Fire District Legal Description -,(3 Ve 5 0It%1 2 b o 63 2-- Site Address(Please include street name,street number and city) 2 80 NE l.A0 RIOgrf DR 6"R 4$5�' Directions to site Will timber be cut and sold in parcel preparation?Yes/ Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs ] 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Y TYPE OF JOB-New Add Alt Repair Other PRIMARY RESIDENCE SEASONAL ❑ Use of Buildings Describe Work • c No.of Bedrooms —No.of Bathrooms Square Footage- 1 st Floor I b 3 2nd Floor 3rd Floor Basement Deck Covered Deck Other — Sq.ft. Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION -Make Model Year Length Width Serial No. No.of Bedrooms No. of Bathrooms Type of Heat Purchase Price$ 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.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 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 WORK IS BY MEANS OF A PROGRESS INSPECTION. p X�x �ilfOM f�GMfS/1K/ By'e� _ate: t�L s 0 Owner/Owners Representative!Itontractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by r I Date aZo� 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 1 10-,60 • ?D 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 NO. PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar-P.O. Box 186,Shelton,WA 98584 Shelton(360)427-r7t •Belfair(360)275-4467•Elma(360)482-5269 n t e web www.co.mason.wa.us APPLICANT INFORMATION 4e8 AGtTV. CONTRACTOR INFORMATION Owner SlfkNk Company Name OM HO S 6Alei, Mailing Address Mailing Address City State Zip Code City State Zip Code Phone Other Ph. Phone Other Ph. Lien/Title Holder Contractor Reg.# Exp. E mail address E Mail Address Drivers Lic.# DOB 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 - I I Z:� Fire District Legal Description t5nuj_ Site Address(Please include street name,street number and city) - r , Directions to site Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 1596 TYPE OF JOB-New Add Alt Repair Other Use of Building Location of Fixtures/Units- 1 st Floornd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNlp; Type of Fixture No.of Fixtures Fees Fuel Type:Electric_LPG—Natural Gas_Heat Pump_ Toilets Type of Unit No.of Units Fees Bathroom Sink Furnace Bath Tubs Heatpumps Showers 2- Spot Vent Fan Water Heater Propane Tank Clothes Washer / EmletStove Kithen Sinks Dishwasher Exhaust Hood Hosebibs 71 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 1 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 OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X e.(1,grof domCS 1XIC • :e1e Date: •r¢ Owner/Owners Representati Contractor (indicate which one) FOR OFFICIAL USE BEYOIy THISPOINT Accepted b Planning Pd Ck# Date �`tt as 09 Bld Pd Receipt No. DEPARTME TAL REVIEW APPROVED DENIED NOTES Building Department Occ Group T 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 I Violation Fee TOTAL FEES