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Request To Revise An Approved Plan
Permit Number: BLD aC)09 - 00 18 3 Name c �50 r) 1 jA
Parcel Number 1 as 3a - .31 - Q00co0 Phone Number daytime ( BUD) _ _ 8D I GG 11 ,17
Project Address 1o09 D E V LIj Mailing Address
Please provide a complete, detailed description of the proposed revisions to the approved plans:
O v e /` E
1 L1
L r w >
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes, Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes No
If Yes, Is a revised site plan, with all new setback dimensions included with this request.
❑ Yes ❑ No
Additional Information:
Applicant's signature �!—��, Date: ,34q/�do y
Office Use Only Received by:
Date Sent Assigned To Approved By Date
� Original Valuation: $
�' 1 Additional Valuation: $
Sq.Ft. x$ $
Sq. Ft. x$ $
Total New Valuation $
Additional Fees:
Additional Planning Dept. $
Additional Plan Review $
dditional Conditigns /Comments: 'a' 1 Additional Building Permit $
l d L.mo m Additional Plumbing $
Additional Mechanical $
Additional E.H. Dept. $
Other $
Total Amount Due: $
Amount To Be Paid Up-Front$
oeA
t raPp ulle to
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04
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a �100
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ao
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s; PLANNING .
ALL SETBACKS ARE MEASU
RED
�4-'o.� `' FROM THE FURTHEST
PROJECTION OF THE BUILDING
APPROVED ��,� � � -�- � a�
MASON COUNTY TY DCD PLANNING PLANNING
:
SITE PLAY REOUI-)ED TO BE ON SITE j "f;'�-.
CHANGES SU W ECT TO APPROVAL
,177
_ `-�
By _ — Date
: RECEIVED
;., MAR 192009
`� ,I MASON COUNTY
Mason County Planning Intake Checklist
Owners Name: !oc+cA �Sn►'1 Date: C3119 1.0 9
Project: 11EU) S-FP_) I Reviewed By: LL.-1
Proposed use(s) of structure(s) LivinQ
Commercial Development: YES NO PLANNER: BM SW PBC CMRC AHB
Site Plan:
/ar North Arrow ❑ Survey required in Allyn UGA — ❑ AF# ❑ Monuments
_,.�" Property Dimensions: X u I&A,UIe-U J'0+-
� Streets and Driveways Shown. Road name: �(�E' V to iAJ �v P?cj
tbacks and use h d n S� PIA rL
� ell Location, a tic an Drain-fiel wn wi se ac s
e ce r , ponds, shoreline, wetlands, natural or historic drainage, defined
drainage ditches) -
Topography (slopes) 5-I 0-- d41o� -you ice,—}-h,¢.,e �rn UL
Minimum Structure Setbacks (Direction/Se b TD
F: \AJ R: _ e _/ 1: QJ_-10 S2: �J
Utility and Drainage Easements: Yes No (if yes enter condition #5022)
Other Easements
Accessory Appurtenances: opa / H tpu p -- ,-}-�, r�n S�t�, Pl,� n
Does site plan show landing all exits?
Variance applied for: Yes / No - parking spaces allotted? Yes No
❑ County Access Permit Neede add condition #0010)
Li State Access Permit Needed (add condition #0020) sew ��I�
Standard Conditions to be added to all Building permits that planning reviews: #5019 and #07 0
J,
Site Access: Are there an impediments (dogs/gates) that my restrict access to your site? 0
Is the site clearly marked? How? Address 6s+eal 4-+ Dn v
❑ Name
Zoning: ❑ Other:
Co . Plan: Rural Zoni UGA Zoning:
Rural ❑ RR 2 5 0 20 ❑ RT/RTC ❑ R-1 ❑ R-5 ❑ HC ❑ BI
❑ RAC ❑ RMF ❑ Unknown ❑ R-1P ❑ R-10 ❑ LTA ❑ VC .
❑ Allyn UGA ❑ RC 1 2 3 ❑ Agricultural ❑ R-1R ❑ PD ❑ FR ❑ T 1�
❑ Belfair UGA ❑ RI ❑ In-holding ❑ R-2 ❑ PF ❑ MU ❑ MHP
❑ Shelton UGA ❑ RNR ❑ LTCFL ❑ R-3 ❑ POS ❑ GC ❑ BP
❑ Tribal ❑ GC- I
Critical Areas: (streams, ponds, shoreline, wetlands, steep slopes) +
Shoreline Cl.
Designation: ❑ N/A Urban ❑ Rural ❑ Conservancy ❑ Natural ❑ Unkow ( Q
V
Water Bodyof ;In
r if unnamed): �ban (�U �
(type )
SEPA: Yes/ No nkn Flood Plain: YES/NO6;)hMap#
Aquifer Recharge: ES/NO Ur6n4 Map#
Ta ases:
RL /S ase: -5,P I 6-Year Dev. Moratorium: YE /
Ea . est Tag: Y NO Other/North Bay Sewer Y NO
Revised 01-13-2009
NameTodd-OSUG- Parcel# 301 , 3 1- 0006&0 BLD#
TQX�Sa fl
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.
ram,^
Surface Type Length X Width = Area *All dimensions in feet
Buildin s X =
a46
X = N4 Measurements for buildings are taken at the
X _ perimeter of the farthest projections(example:
U3 eaves/gutters)
MUATbr 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
X _ above table
Patios/Walks X =
X = Any paved, gravel or packed area per definition
X _ above table
Others X
X = a fe roposedi
XMMENMERMNOMMM-1�-7)117
= aeYre ee
1>
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.
Page I of 2
_ I
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.
'I'itle 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:
http/—/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) The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
eir entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel.
B An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the
sy 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/d rain field 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 wn Agent/Contractor(circle one)Date: Q
Page 2 of 2
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.mason.wa.us �=
APPLICANT INFORMATION < CONTRACTOR INFORMATION
Owner :!:: " /6.7 Company Name
Mailing Address - Mailing Address
City State ' " Zip Code City State Zip Code
Phone iOther Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address t�+W s N <a�y t^�.r, - t `tl ] 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 Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Digit Par el No. Fire District
Legal Description ?3 tAJ ' :1- ?rL-al` 11, `
Site Address(Please include street name, street number and city) '
Directions to site
Will timber be cut and sold in parcel rep ration?Yes/
Is property within 200' of SaltwaterS Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluff/o
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - Newj�,__Add Alt Repair Other PRIMARY RESIDENCE Q SEASONAL ❑
Use of Building , t Describe Work r
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor " <.f 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.
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 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 INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THEAPPLICATION.
X ..�''���'�a=fm' , ,,- Z = Date: st r H
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVEP DENIED I NOTES
Building Department
1119
Planning Department I
Environmental Health Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee 9 2 ?. .Z Z EH Review Fee
Plumbing & Base Fee / . 4(4f y ?O Planning Review Fee
Mechanical & Base fee 9 3- /�/ -SAD Other
Wood /Gas/ Pellet Stove Fee ��_ GO�� State Fee
Violation Fee --Z�- Pre-Paid at Submittal
Valuation $ TOTAL FEES
MASON COUNTY i PERMIT NO.f) IJc2&_" ' W(� 3
PLUMBING/MECHANICAL 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 Q Company Name
Mailin Addres _ Mailing Address
City V—State
t1 Zip Code City Mate Zip Code
Phone �° Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg.# Exp.
E mail address E Mail Address
Drivers Lic.# .S' A)SOTA3 20L=:DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septi Connect to Sewer System
Name of Sewer System hl,e>SC'r�t' 47IQ
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal DescriptionIll, I w 44 -1 -_.Z
Site Address (Please include street name, street number and city) Cz1W ul,e
Directions to site 2== F` C'Jeo
>I c Ic .
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
TYPE OF JOB - New--)(-Add Alt Repair Other Use of Building
Location of Fixtures/Units - 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNyTSffU
Type of Fixture No. of Fixtures Fees Fuel Type.Electric✓_✓ LPQz._L_ Natural Gas Heat Pump_
Toilets Type of Unit No. of Units Fees
Bathroom Sink Furnace
Bath Tubs -1 Heatpumps
Showers �— Spot Vent Fan �C 5-
Water Heater Propane Tank 1
Clothes Washer I Ochen
Outlets
Kithen Sinks I /Gas/Pellet Stove
Dishwasher Exhaust Hood /
Hosebibs 4— Dryer Vent l
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 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.
X r iYY/� Date:— � Z!Zl
Owner/Owners-Representative/Contractor (indicate which one)
ti FOR OFFICIAL USE BEYONpTHIS POINT
Accepted by: Planning Pd Ck# Date 6.1 I q Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group—Type Constr.-
Planning 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