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MASON COUNTY TENANT REVIEW APPLICATION Complete the Tenant Review Application and return with a floor plan, site plan,septic pumper's report, septic records and $141.00 fee to the Mason County Permit Center, P.O. Box 186, Shelton,WA 98584. During the evaluation of your Tenant Review Application staff members from the Building, Fire Marshal, Environmental Health, Planning and Public Works offices will identify compliance requirements. This application is intended for tenant change only. If construction or remodeling is proposed/required a separate building permit will be necessary, Upon approval the permit will be issued to the applicant/tenant. After the permit is issued, schedule a site inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be osted in a cons icuous elace on the premises. a t 1 ' .'K'9 ' '`x ,✓,:.;'"a o.. Date: 53—( r Assessor's Parcel Number. 'aJL Legal Description: _16 �— Building Site Address: 2 Method of sewage disposal: ® Septic O Sewer—name of district: Water source: O Individual Well O Community Well ®Public System, name of system: RM I I MIN Name of Applica �..s Mailing address:�� City: State: Zi E-Mail Addres G Day phone: FAX phone: Contact Person. ;%� 17 Proposed business name: � � .. Proposed use: ` Number of employees: Previous business name: � }}Describe previous use: Pte � _.:h x; $',.^.... � ,.Check one: '& Detached single level/singlnant O Single level/multi tenant O Multi level/single tenant O Multi level/multi tenant Ag,Q of structure: Is structure currently If not occupied, how long has it be n vacant? occupied? 'Yes No Yrs mos. G Square footage: I Basement: I First:E-2� Mezzanine: Second: zaoo Third: Is the stru re heated? I Heating type: Circle one: Circle one. s No F"vA Electric Liquid Propane <39WWral Ga Oil Type of hea : Circle on(. Fur n c Heat Pump Electric baseboard or wall mount Radiant i ere be any changes to the following? Circle yes or no, if applicable: Floor lay-out: Yes9-0-0) Lighting: Ye� Heating: Yes��g Exterior Finishes: YesInterior Finishes: es No Parking: Ye Number of restrooms provided: I Number of fixtures in each 2— Is structure handicap accessible? Circle one Y No Is the structure equipped with a fire sprinkler system? Yes No Fire alarm system? Yes No Monitoring Station Name: I A4071�- _ Phone number:"78 o hl If 1. Floor Plan(5 sets): • Draw the floor plan to scale Use of rooms • Room Dimensions • Location of all exits and windows (include dimensions) • Location of plumbing and mechanical fixtures • Interior doors with swing radius 2. Site Plan (5 sets): Note scale used • Property lines, easements, &right of ways • Location of all existing structures&dimensions • Distance, in feet,from property line&structures • Landscape buffer yards • On-site sewage tanks and drain fields, &reserve • Well location • Surface&storm water run-off routes • Parking areas(number&arrangement) • Location of fire hydrants&vehicle access roads 3. Septic records,pumper's report or O&M report. 4. Fees will be collected at time of submittal. Balance due will be cGU6cted when the permit is approved and issthid. Accepted by Date Submittal Amount$ Receipt number Department Review Initials Date Comments Building Environmental Health Fire Marshal Planningr'�� ,�� t✓1 � t' C y 1 tip(."t�. Public Works v Pre Application required? (circle one) Yes No Building Permit required? (circle one) Yes No Engineering Required? (circle one) Yes No Type of construction Occupancy Change? (circle one) Yes No New Occupant load: persons Occupancy classification change from to Existing occupant load design persons. Valuation: $ co MASON COUNTY TENANT REVIEW APPLICATION Complete the Tenant Review Application and return with a floor plan, site plan, septic pumper's report, septic records and $141,00 fee to the Mason County Permit Center, P.O. Box 186, Shelton,WA 98584. During the evaluation of your Tenant Review Application staff members from the Building, Fire Marshal, Environmental Health, Planning and Public Works offices will identify compliance requirements. This application is intended for tenant change only. If construction or remodeling is Proposed/required a separate building permit will be necessary, Upon approval the permit will be issued to the applicant/tenant. After the permit is issued, schedule a site inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be _posted in a conspicuous elace on the premises. . fay s ,. r {`- ,.. ...,.., Date: �-- ` . Assessor's Parcel Number: a, Legal Description: Building Site Address: •. 2 Method of sewage disposal: ® Septic O Sewer—name of district: Water source O Individual Well O Community Well ®Public System, name of system: Name of Applica �'� Mailing address:�� t City: State: Zi . E-Mail Addres G �� Day phone: FAX phone: Contact Person. fi o Proposed business name: --C' �Q--�� � Proposed use: ` Number of employees: Previous business name: � Describe previous use: o- .':''�cc x ,:.i -:-d°..-.s ". .: t, ..='� A"3...`pr. ..,.. «y '.. `�""£: ,�� .K, Check one: IS Detached single level/single tenant O Single level/multi tenant O Multi level/sin le tenant O Multi level/multi tenant Acm of structure: Is structure currently If not occupied, how long has it be n vacant? occupied? Yes No Yrs mos. � G Square footage: I Basement: First:12,, Mezzanine: Second: QL-)O Third: Is the struclLre heated? Heating type: Circle one: Circle one. s No (tiV'Vl Electric Liquid Propane ral Ga Oil Type of hea . . n c H Circle on Fureat Pump Electric baseboard or wall mount Radiant i ego ho anv chances to the following? Circle yes or no, if applicable: Floor lay-out: Yes9-0--"o ]eating: Yes Exterior Finishes: Yes larking: Ye Number of restrooms provided w,4-1 Is structure handicap accessib � t " Is the structure equipped with harm system? Yes No Monitoring Station Name: ie number: NO 1. Floor Plan(5 sets): • Draw the floor plan to scale • Room Dimensions ` \ J II exits and windows (include dimensions) • Location of plumbing and mr i with swing radius 2. Site Plan(5 sets): Note �`Y'' • Property lines, easements, 1 67 II existing structures&dimensions • Distance,in feet,from prope suffer yards • On-site sewage tanks and d • Surface&storm water run-( is (number&arrangement) • Location of fire hydrants&vernue;dLyvao 3. Septic records,pumper's report or O&M report. 4. Fees will be collected at time of submittal. Balance due will be cGUAicted when the permit is approved and isslMd. Accepted by Date Submittal Amount$ Receipt number Department Review lnKW Date Comments Building Environmental Health Fire Marshal Planning Public Works Pre Application required? (circle one) Yes No Building Permit required? (circle one) Yes No Engineering Required? (circle one) Yes No Type of construction Occupancy Change? (circle one) Yes No New Occupant load: persons Occupancy classification change from to Existing occupant load design persons. Valuation: $ co MASON COUNTY TENANT REVIEW APPLICATION Complete the Tenant Review Application and return with a floor plan, site plan, septic pumper's report, septic records and $141.00 fee to the Mason County Permit Center, P.O. Box 186, Shelton,WA 98584. During the evaluation of your Tenant Review Application staff members from the Building, Fire Marshal, Environmental Health, Planning and Public Works offices will identify compliance requirements. This application is intended for tenant change only. If construction or remodeling is Proposed/required a separate building permit will be necessary, Upon approval the permit will be issued to the applicant/tenant. After the permit is issued, schedule a site inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be _posted in a cons icuous Elace on the eremises. � - v � ���Asses�sors.P�arcel�Numbe�r,� �-O, Date: �-- - Legal Description: Building Site Address: 2 Method of sewage disposal: ® Septic O Sewer- name of district: Water source: O Individual Well O Community Well ®Public System, name of system: � m Name of Applica Mailing address:�V-)o L City: State: Zi E-Mail Addres �� Day phone: FAX phone: Contact Person. L a Proposed business name: --- �Q- Proposed use: c6&iML , rien 12 e>fcp vn Number of employees: Previous business name: Yl Describe previous use: s z 7 Check one:4 �* Detached single level/single tenant O Single level/multi tenant O Multi level/single tenant O Multi level/multi tenant Aga of structure: Is structure currently If not occupied, how long has it be n vacant? occupied? 'Yes No Yrs mos. G Square footage: Basement: First:t Mezzanine: Second: Third: Is the struqture heated? Heating type: Circle one: Circle one. s No �V V Electric Liquid Propane ral Ga Oil Type of hea : Circle on . Furn c Heat Pump Electric baseboard or wall mount Radiant ere be any changes to the following? Circle yes or no, if applicable: Floor lay-out: Yes k Lighting: Yes Heating: Yes Exterior Finishes: Yes Interior Finishes: es No Parking: Ye Number of restrooms provided: t Number of fixtures in each Z Is structure handicap accessible? Circle one Y No Is the structure equipped with a fire sprinkler system? Yes No Fire alarm system? Yes No Monitoring Station Name: Phone number:-72S 1. Floor Plan(5 sets): • Draw the floor plan to scale Use of rooms • Room Dimensions • Location of all exits and windows (include dimensions) • Location of plumbing and mechanical fixtures • Interior doors with swing radius 2. Site Plan (5 sets): Note scale used • Property lines, easements, &right of ways • Location of all existing structures&dimensions • Distance,in feet,from property line&structures • Landscape buffer yards • On-site sewage tanks and drain fields,&reserve • Well location • Surface&storm water run-off routes • Parking areas(number&arrangement) • Location of fire hydrants&vehicle access roads 3. Septic records,pumper's report or O&M report. 4. Fees will be collected at time of submittal. Balance due will be coHicted when the permit is approved and issLMd. 10,Al Accepted by Date Submittal Amount$ Receipt number Department Review Initials Date Comments Building Environmental Health Fire Marshal ( _ Planning Public Works Pre Application required? (circle one) Yes No Building Permit required? (circle one) Yes No Engineering Required? (circle one) Yes No Type of construction Occupancy Change? (circle one) Yes No New Occupant load: persons Occupancy classification change from to Existing occupant load design persons. Valuation: $ MASON COUNTY DEPARTMENT OF HEALTH SERVICES May 18, 2009 PO BOX 1666 Shelton WA 98584 Shelton (360)427-9670 Fax (360)427-8442 JACK JOHNSON Elma (360)482-5269 PO BOX 1119 BELFAIR WA 98584 Belfair (360) 275-4467 Case No.: COM2009-00051 Parcel No.:123325000063 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. Please see comments at the end of this letter. Please call me at(360)427-9670, ext. 279 if you have any questions. Sincerely, Amanda Reynolds Environmental Health Mason County Health Services Comments: Need satisfactory pumpers report 5/18/2009 1 of 1 COM2009-00051