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pots cvp MASON COUNTY COMMUNITY SERVICES
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r 615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone
Belreir.;(360)275-4467•Phone Elma:(360)482-5269
:' G
- ' RECEkob
M IL CIO -12 h BUILDING PERMIT APPLICATION
PROPERTY OWNER INFORMATION: CONTRACTOR INFO
615 W. Alder Street
NAME: � I NAME:
MAILING A D S: MAILING ADDRESS:
CITY: STATE: ZIP: CITY: STATE: ZIP:
PHONE#1: PHONE: CELL:
PHONE#2: EMAIL :
EMAIL: L&I REG# EXP. / 1
PRIMA Y CONTACT: OWNER❑ CONTRACTOR❑ OTHER
NAME EMAIL �- "'SON e J
MAILING DR 1 _ CITY 5 STATE ZIPIG
PHONE CELL - _ O
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) �52:Z,3450 -D0d 3 ZONING "i'R -5
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
.SITE ADDRESS rL �4 / /(�, N� � \:S1y0,eJF_ mg-p CITY
DIRECTIONS TO SITE ADDRESS M496T foti 16 L F4f/e CJ�Cr ,-7/
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NOX
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER LAKE❑ RIVER/CREEK❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF❑ STREAM ❑
TYPE OF WORK: NEW)( ADDITION❑ ALTERATION ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) '/i1_1().4
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS Z-
HEATED STRUCTURE? YES(Whole Bldg) YES(Part[s]of Bldg) ❑ NO ❑
DESCRIBE WORK t4ir f1h6k, bQ67Q�rel /04V 70-40 IJ )
SQUARE FOOTAGE: (propose+exlsang)
I ST FLOORM!? sq. ft. 2ND FLOOR sq.ft. 3RD FLOOR A)4 sq.ft. BASEMENT NA sq. ft.
DECK__ sq.ft. COVERED DECIC`7_ sq.ft. STORAGE �d sq. ft. OTHER sq. ft.
GARAGE 3 sq. ft. Attached Detached❑ CARPORT sq. ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW EXISTING❑
PLUMBING IN STRUCTURE? YESK NO❑ Ijyes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES NO❑ EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS
OWNER 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 and 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 legal
representative,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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON
COUNTY CODE 14.00.42)
X
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT J7Z
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
MASON COUNTY RECEIVED
i COMMUNITY SERVICES APR 2 7 2017 ®� � r
Building,Planning,Environmental Health Community Health
615 W. Alder Street
Physical and Mailing Address: 615 W Alder St., Bldg 8, Shelton, WA 98584
Shelton Phone: (360)427-9670 ext 352 Fax (360)427-7798
PLUMBING & MECHANICAL PERMIT APPLICATION Permit#:
-OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: NAME:
MAILING ADDRESS: o l e)�L MAILING ADDRESS:
CITY: fl STATE:_ZIP: ' CITY: STATE: IA ZIP::::: 3`
1I PHONE: D - PHONEf '2G3' %'/'/CELL:
2nd PHONE: 3hn -�? I C d`i'� ° l� EMAIL
EMAIL r1 r'�c r ;� '� I�,c��'� r1� �F - ui L&I REG# EXP.
PARCEL INFORMATION: ( _
PARCEL NUMBER (12 Digit Number): \j �'� ' `x' Zoning: r� -
LEGAL DESCRIPTION (Abbreviated):
SITE ADDRESS: 13 6 L4 1 Y)C 1 oe H'L_ 5 CITY:
DIRECTIONS TO SITE ADDRESS:
TYPE OF JOB/WOB,K: NEW DD_ ALT REPAIR OTHER
USE OF BUILDINGIu
PLUMBING FIXTURES MECHANICAL UNITS []Electric in-wall heaters(nofee)
Type of Fixture No. of Fixtures Fuel Type Fees Type of Unit No. of Units Fuel Type --
Toilet(s) Z- Furnace [E/G
Bathroom Sink(s) �—— Heat Pump _ EIG/LPI
Bath Tub(s) f O Ductless H.P. /LPG]
Shower(s) Spot Vent Fan
Water Heater(s) / ([EpG/LPG] Propane Tank L--9a1"]
Clothes Washer(s) / [E/G/LPG] Gas Outlet(s)
Kitchen Sink(s) / Heat Stove [�G/LPG
Dishwasher(s) Kitchen Exhaust Hood 1
Hose bib(s) Dryer Vent i
Other Solar Panel
Other Other
Plumbing Subtotal Mechanical Subtotal
Plumbing Base Fee Mechanical Base Fee
Final Inspection Fee Final Inspection 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 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
INSPECTIO .INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X t,� -1 � 17 -
o Signature of Applic n.k Date -�
X ��� l�7 Owner/Owners resent tive/Contractor
Pr Name (Circle one) jl i LG
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
O Building
O Fire Marshal
O Permit Tech (OTC permit only)
ReV:3!CFI��-
Name Parcel# �Z� -- l�3sv BLD# 1' 5 4
BUILDING Mason County R
Department of Community Development APR 2 7 2017
Small Parcel Stormwater Management Application/Worlij§4 pAgt.�,gfA
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.
To Calculate Impervious Surfaces Please Complete This Table
Surface Type Length X Width = Area *All dimensions in feet
Buildings Z X _ s g
X = Measurements for buildings are taken at the
X _ perimeter of the farthest projections(example:
eaves/gutters)
X =
Driveways X 7-6
X = Length of drive begins at the right of way
X =
Parking Areas J(IA X =
X = Any paved, gravel or packed area per definition
above table
X =
Patios/Walks c,� X ---�5
X = Any paved, gravel or packed area per definition
above table
X =
Others X =
X = If the total impervious area of the proposed site
X = development is greater than 2000 square feet a
Small Parcel Stormwater Site Plan is Required
Total Impervious Surface Area(sum of 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 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-
describel#operty for review.and inspection as may be required.
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 4 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 14AS 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
in their 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
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
100 W.Public Works Dr
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 400
415 N. 6th St—Bldg#8 lower level
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 Owner/Agent/Contractor(circle one)Date:
Page 2 of 2
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