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MASON COUNTY PERMIT NO. Qa)d
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING•PLANNING•FIRE MARSHAL
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason County Bldg. III,426 West Cedar Street (360)275- 467 Belfair ext. 352
1854 PO Box 279, Shelton,WA 98584 (360)482-5269 Elma ext. 352
BUILDING PERMIT APPLICATION
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: e�G �4V S NAME: � ffe J g �� I-/91 , A e_j
MAILING ADDRESS:�� C fi MAILING ADDRESS:
CITY: All STATE: Z] :��5/ CITY: STATE: ZIP:
PHONE: CELL:,�loD S S/- 9�y PHONE: CELL:
EMAIL: i S �73��yGL/so Leo Iki EMAIL :
L&I REG# EXP.
PARCEL INFORMATION:
PARCEL NUMBER(12 DIGIT NUMBER) � ���_�,,���-73 FIRE DISTRICT
LEGAL DESCRIPTION(ABBRE TED):
SITE ADDRESS / J CITY41
DIRECTIONS TO SITE ADDRESS '
►''— a
IS PROPERTY WITHIN 200 FT:
SALTWATER❑ LAKE ❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
DOES PROPERTY HAVE SLOPE(S)WITHIN 300 FT OF THE PROJECT-GREATER THAN 14% YES❑ NOk
TYPE OF JOB: NEW ❑ ADDITION [& ALTERATION❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(RESIDENCE,GARAGE ETC.) an L4�!Zrn Q
IS USE: PRIMARY ❑ SEASONAL NUMBER OF BEDROOMS NUMBER OF BATHROOMS
DESCRIBE WORK
VL
SQUARE FOOTAGE: 3 2014
I ST FLOORra_,_sq.ft. 2ND FLOOR sq. ft. 3RD FLOOR sq. ft. BASEnT r t',sc fit:
DECK sq. ft. COVERED DECK sq.ft. STORAGE sq. ft. OTi P&- Y sq. ft.
GARAGE sq. ft. ATTACHED ❑ DETACHED ❑ CARPORT sq. ft. ATTACHED ❑ DETACHED
MANUFACT D HO INFORMATION: *4 COPIES OF THE FLOOR PLAN
MODEL LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
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 contractor. I further
declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary
parties, including any easement holder or parties of interest regarding this project.The owner or authorized agent represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structure(s)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 OF
I SPEC I N. IC`ACTIVITY OF IS PE MIT APPLICATION OF 180 DAY L INVALIDATE THE APPLICATION.
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ignature of Applicant e
719NE / REPRESENTATIVE /CONTRACTOR
Print Name (CIRCLE TO INDICATE)
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
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SITE PLAN REQUIRED TO BE ON SITE
CHANGES SUBJECT TO APPROVAL
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Name I l 1 Parcel# BLD#
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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?.
'Redevelmment means,on an already developed site,the creation or addition of impervious surfaces,structural development
including construction,ins-allation 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 matsrials,and oiled,macadam or other surfaces which similarly impede the
natural infiltration of storrnwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
T�-Ca1c.""mate Impery ous' S`iir�ces �.feasb Comp
Surface Type Length X Width = Area *All dimensions in feet
Buildings X =
X = Measurements for buildings are taken at the
perimeter of the farthest projections(example:
X = 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
;N
PatiosMfalks X = y"
X = Any paved, gravel or packed aruwr�flfir.
above table
X =
An I
Others X -
X total_impervious area of the proposed-site
X = development is.-greater than_2DDD,square feet a
Small Parcel.Stomiwater.Site.Plan:is Required.:,
Total Impervious Sutiace Brea(sum bf all areas).
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 Storrnwafer Sfte Plan IS NOT required for this development activity.
O-AmerBuilder/Agent Acknowledges that submission of inacmuate 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 pr perty for review and inspection as may be required.
AaeA� 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 1 of 2
Name Parcel# BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/PVorksheet (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:
httD//,A,ww.co.maSDn.,Am—us/c,Dde./commissioDers/*Lndff,x.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 14.49.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 detatZs from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
in their entirety AND the system will be Iocated 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
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 consuh 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 strop 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-
descnbed property for review and inspection as may be required.
X Owner/Agent/Contractor(circle one)Date
Page 2 of 2