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Home My WebLink AboutBLD2020-00720 Final MFG Home - BLD Permit / Conditions - 12/17/2020 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg.8 Shelton, WA 98584 360-427-9670 ext 352 www.co.mason.wa.us B DD2020-00720 MANUFACTURED HOME PROJECT DESCRIPTION: NEW MFG HOME ISSUED: 12/17/2020 SITE ADDRESS: 330 E DARTMOOR DR SHELTON EXPIRES: 06/15/2021 PARCEL: 321275300099 APPLICANT: JENSEN BAKKEN HOMES LLC OWNER: JENSEN BAKKEN HOMES LLC 221 E BALLANTRAE DR 221 E BALLANTRAE DR SHELTON,WA98584 SHELTON,WA98584 360.401.0140 FEES: Paid Due State Fee-Residential $6.50 $0.00 Technology Surcharge $11.00 $0.00 Building Plan Review/Change of $110.00 $0.00 Use-Onsite Sewage Planning Review Fee $240.00 $0.00 Modular/Manufactured Home $275.00 $0.00 Fee-2nd half collected at ready to issue Modular/Manufactured Home $275.00 $0.00 Fee- 1st half collected at submittal Totals : $917.50 $0.00 REQUIRED INSPECTIONS Setback Inspection Set-Up Inspection Footing Inspection BLD-Final Inspection CONDITIONS " Owner/Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28 and 14.17. Printed by:Genie Mcfadand on:12/17/2020 02:19 PM Page 1 of 4 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg.8 Shelton, WA 98584 360-427-9670 ext 352 www.co.mason.wa.us MANUFACTURED HOME BLD2020-00720 The installation permit shall be displayed in clear view of the site access road. The approved site plan and other applicable instructions, including installation instructions, shall be available in this location OR placed in the location specified by WAC 296-150M-655. Support configuration shall be clearly marked in the installation instructions. * Approved per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure. The foundation/footing must be placed on undisturbed,firm-native soil. A Mason County Stormwater Management Worksheet was completed and signed as part of this building permit application. Design, sizing, placement, inspection and maintenance of stormwater management systems shall be the responsibility of the owner/agent of the developed parcel. It is the owner/agent/contractor's responsibility to ensure that Mason County Department of Public Works has approved the stormwater site plan for this parcel prior to the commencement of any development activities. *NOTE if Stormwater Management option "A"was selected on the Small Parcel Stormwater Management Application/Worksheet the document entitled"Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan"constitutes an approved plan based on the criteria listed on the application/worksheet. If the development has, or will have, a septic/drainfield system you are responsible for contacting 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. By calling for a final inspection of the building permit the owner/agent/contractor is acknowledging that all components of the stormwater management system have been installed as approved on the stormwater site plan. Provisions for surface/subsurface drainage control must be implemented with new construction or development on site and MUST NOT adversely impact adjacent parcels. Under the requirements of Mason County Stormwater Ordinance, either private ditches and drains will meet requirements of the stormwater ordinance or prior approval will be granted to use an existing utility and drainage easement dedicated for that specific purpose. For further information regarding this ordinance and the REQUIREMENT to obtain an ACCESS PERMIT for the installation/construction of a driveway or access connecting from a Mason County Road, Contact the Mason County Public Works Department prior to construction at Ext 450. For any construction which is proposed to be located within 25'of a Mason County road right of way, it is suggested to contact that office to review future planned work which may affect your project. * All construction must meet or exceed all local and state ordinances in addition to the International Codes requirements as adopted and amended by Mason County and the State of Washington. Occupancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would result in permit revocation. * All permits expire 180 days after permit issuance, or 180 days after the last inspection activity is performed. The Building Official may grant a one time extention of 180 days, upon the receipt of a written extension request prior to permit expiration. Letter must indicating that circumstances beyond the control of the permit holder preventing action from being taken. No more than one extension may be granted. * By definition, propane tanks and heatpumps are structures, which must meet setback conditions. Please check your "Approved Site Plan"to ensure these structures meet the setback conditions listed. 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 INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. * All property lines shall be clearly identified at the time of foundation inspection. Printed by:Genie Mcfarland on:12/17/2020 02:19 PM Page 2 of 4 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg.8 Shelton,WA 98584 360-427-9670 ext 352 www.co.mason.wa.us MANUFACTURED HOME BLD2020-00720 * When parcel development requires direct access to county road(s), a Road Access Permit or Approval must be granted by the Mason County Department of Public Works. For more information contact Public Works, at(360)427-9670, ext.450 or 100 W Public Works Dr. Shelton.The building permit will not be finaled until the permit holder can show proof that the access permit from Public Works has been finaled and approved. * All building permits shall have a final inspection performed and approved by Mason County Building Department prior to permit expiration. The failure to request a final inspection or to obtain approval will be documented in the legal property records on file with Mason County as being non-compliant with Mason County ordinances and building regulations. * All RED stamped approved plans are required to be on-site for inspection purposes. If an inspection is called for and plans are not available on site,then approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and must be collected by the Building Department prior to any further inspections being performed or approvals granted. * This permit is for the placement and installation of the manufactured home only and does not imply approval or review for any other items indicated on the plot plan. * Any retailer, manufacturer or contractor who installs a manufactured home warrants that the manufactured home is installed in accordance with the State Installation code, chapter 296-150M WAC. All installers hired to do installation work shall be certified manufactured home installers and shall be present to supervise the installation of all on-site work. An Installer Tag shall be posted on site giving the certification number and signature of the certified installer responsible for each major part of the installation. RCW43-63B.090 An approved Installer cerification tag shall be placed on the end of the manufactured home directly above or below the HUD certification tag or temporarily located in plain site within three feet of the home's front entry. There shall be one certification tag for each certified installer accounting for the work that each installer performed or installed. Certification number and signature of the certified installer responsible for each major part of the installation.WAC365-210 * Contractor registration laws are governed under RCW 18.27 and enforced by the WA State Dept of Labor and Industries, Contractor Compliance Division. There are potential risks and monetary liabilities to the homeowner for using an unregistered contractor. Further information can be obtained at 1-800-647-0982. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law. * The plan review check list and corrections are part of the approved plans and must remain attached. It is the responsibility of the applicant, owner or contractor to make the required corrections indicated on the plans. Once the plans are marked "APPROVED", they shall not be changed or altered without authorization from the Building Official. The permit holder is responsible to retain the complete approved set of plans on site for the duration of the project. Failure to comply and/or removal of approved documents will result in failure of required building inspections. * Retaining walls needed to support a surcharge such as structures, roads, or to support slopes, shall require a separate building permit and approval prior to construction of the retaining wall. * Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners, connectors, and flashing. Install metal connectors approved for contact with the new types of pressure treated material. * CONSTRUCTION PROCESS TO BE FIELD CORRECTED AS REQUIRED PER MASON COUNTY BUILDING DEPARTMENT AND THE ADOPTED BUILDING CODE. The construction of the permitted project is subject to inspections by the Mason County Building Department. All construction must be in conformance with the international codes as amended and adopted by Mason County. Any corrections, changes or alterations required by a Mason County Building Inspector shall be made prior to requesting additional inspections. * Concrete used for basement walls, foundation walls, exterior walls, porches, carport slabs, steps exposed to the weather, garage floor slabs and other vertical concrete work exposed to the weather shall have a minimum compressive strength of 3000 psi (IRC Table R402.2). Printed by:Genie Mcfarland on:12/17/2020 02:19 PM Page 3 of 4 0 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg.8 Shelton, WA 98584 360-427-9670 ext 352 www.co.mason.wa.us MANUFACTURED HOME BLD2020-00720 " If you are installing a manufacturing home and no longer have the installation manual for the home, you must use the instructions of the American National Standards Institute (NCSBCS/ANSI A225.1). All surface water and potential runoff must be controlled on site and shall not adversely affect any adjacent properties nor increase the velocity flow entering or abutting to any state or county culverting/d itch ing system or road way. REQUIRED INSPECTIONS (Footing Inspection-prior to pour(set-up manual must be on-site), Set-up Inspection-prior to skirting, Final Inspection-prior to occupancy). I hereby assume all responsibility for the scheduling of my required inspections. If the required inspections are not requested, inspected and signed off(approved) by the inspector in the prescribed order, I understand that reinspection fees and an hourly investigation fee pursuant to the current fees adopted by the Mason County Building Dept., and will be assessed in addition to my original permit fees to resolve any questionable practices or problems that have been discovered. Until resolution of any/all problems no occupancy(Final Inspection)will be granted for the residence. OWN ER/CONTRACTOR(indicate which) " The stamped approved site plan is required to be on-site for inspection purposes. If an inspection is requested and the approved site plan is not on site, approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and shall be collected by the Building Department prior to any further inspections being performed or approvals granted. " All changes to"approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County ordinance or regulation, must be reviewed and approved by Mason County prior to construction. * Application acknowledges that the structure is only permitted for a use consistent with the current zoning of the parcel. * Applicant not to remove trees as noted in e-mail dated November 3rd " Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained " Applicant/Owner assumes all responsibility if On-site Sewage Components are encumbered. A.) Drainfield/Reserve requires a 1 Oft setback from all footing/foundations. B.)Septic tank(s) requires 5ft setback from all footing/foundations. C.) No foundation/Perimeter Drains within 30ft, down gradient of Drainfield/Reserve area. D.) No Cut Bank(s)(greater than 5ft and over 45 degrees)within 50ft, down gradient of Drainfield/Reserve area. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of Laws and Ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state/local law regulating construction or the performance of construction. Issued By: CaLu Contractor or AuthorJeAgent: Date: Printed by:Genie Mcfarland on:12/17/2020 02:19 PM Page 4 of 4 MASON COUNTY 615 W.Alder St.Bldg 8,SHELTON,WA 98584 COMMUNITY SERVICES SHELTON:360-427-9670,EXT 352 BELFAIR:360-275-4467,EXT 352 Building,Planning,Environmental Realth,Community Health E LMA:360-482-5269,EXT 352 www.co.mason.wa.us INSPECTION CARD AND CERTIFICATE OF OCCUPANCY" To schedule an inspection call or visit http://www.co.mason.wa.us/community-services/bid-inspection.php Permit Number BLD2020-00720 Date Issued 12/17/2020 Issued By Project NEW MFG HOME Site Address 330 E DARTMOOR DR Applicant JENSEN BAKKEN HOMES LLC Contractor Contractor Phone Primary Code UPC IBC,IRC,IFC,IEC,IMC,& Type Permit Type MANUFACTURED HOME Occupancy -APPROVED PLANS MUST BE ONSITE FOR ALL INSPECTIONS. -DO NOT PROCEED BEYOND EACH STAGE OR COVER WORK UNTIL APPROVAL IS GRANTED. -THIS CARD MUST BE POSTED IN A CONSPICUOUS LOCATION,FRONT OF THE PREMISES IS BEST FOR MAKING ENTRY. -ALL PERMITS EXPIRE 180 DAYS AFTER THE PERMIT IS ISSUED OR 180 DAYS AFTER DATE OF LAST INSPECTION. -OWNER/AGENT IS RESPONSIBLE FOR REQUESTING ALL INSPECTIONS THROUGH FINAL INSPECTION. "THIS STRUCTURE MAY NOT BE USED OR OCCUPIED UNTIL ALL APPROVALS ARE GRANTED." PRIOR TO CALLING FOR FINAL INSPECTION,ALL CONDITIONS OF THE PERMIT MUST BE MET Public Works Access/Driveway Other Health Septic Well Deptartment Planning Site Inspection Department Fire Marshall Fire Apparatus Access Fire Sprinkler Auto Fire Alarm Hood and Duct Other Final Building Building Official: Community Services Designee Department Concrete Setbacks Slab Footing Perimeter Point load Footing Footing Interior Footing Decks/Porches Foundation Stem Walls Other Rough-In Groundwork Plumbing Framing Groundwork Mechanical Plumbing Groundwork Gas Pipe Mechanical Gas Piping Shear Wall Nailing Underfloor Other Insulation Slab Ceiling Floor Vaulted Ceiling Walls Vapor Barrier Other Wallboard Interior Wall Brace Panels Fire Walls Nailing Other Final Building Manufactured Setbacks Setup Home / `z� � G Y-19'2 1 CLM Concrete Foot/Runners 'Z 8 (fir• ( ,5 L Final Other final 6=atl� 5-1e -20 , CLM See . - 6 6-1 2ro — Dor-tmvor or-- Pia+ PIA Y\ clrm �)tnsfh BojKKen { ONS(1G c .FarCt1#3212.7-53-0009q 330 E Dartmoor Dr ' SCol({: L 30, 5 LA o CS 30 ys 60 �CopoS Pd Key OCleanout d O 1,200 Gallon Septic Tank Add riStr -4- 1;d -to Sor4acr q i D-Box with speed-levelers b`rJ�h r ck& cover to surface i siop� x�Sty nq DF Per 45bvt i+ -7//I/Ig87 M 3'x 3 S' 6e5ervc �tPhC htiS APPROVED 5.00349 PAULA JOY JOHNSON' C DEC 17 2020 MASON COUNTYENVIRONMENTAL HEALTH LYC !f•,J .w N 1�0 ,cif 'A'� 1 � Y a by-c No --' Pole - Pf Pr QPo ,- "v 1e pelIVt wt4y �" , APPROVED 4kk k e-4 pome SS tic MASON COUNTY DCD PLANNING ` E SITE PLAN REQUIRED TO BE ON SITE .3 0 �' YY1 p '' °� + �! e t �,� C NGE SUBJECT TO APPROVAL By Date PAvoc e'. 3 2 S'3 —Poo PLAN LOT REVISION DATE /7� I I e CD a list tU , r NVII I �- i I •�{ r + v11 I i ,i i I r — , r i i Name J-eNSC-N-aR f"l5 Parcel# 3 Zl L7- �3 ,OdDy�f BLD#_ �C l V' 1r Mason County JUL 13 2020 Department of Community Development W5 W.Alder ,':0 ,G Small Parcel Stormwater Management Application/R'orksheet (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. To Calculate Impervious Surfaces Please Complete This Table Surface Type Len th X Width = Area '"All dimensions in feet Buildin s S ' X 2-7' = /07— X = Measurements for buildings are taken at the X = perimeter of the farthest projections(example: X = eaves/gutters) Driveways X = 60Av,5L 041, X = Length of drive begins at the right of way X = Parkin 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 = 1111111 X = If the total impervious area of the proposed site X = development is greater than 2000 square feet a Total Impervious Surface Area (sum of all areas Small Parcel Stormwater Site Plan is Required 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. Qwne gent/Contractor(circle one Date: > 3 Zp 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 Name7Gnisi—W 9,4" 4V1V-5 Parcel it 32/27—63 -oOD BLD# dow 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: httv//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. q p s complex es. A design by a registered professional may be required for more it pp *These details are found in the document Managing ng 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 ) The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed i 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 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 rther acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- scribed property for review and inspection as may be required. X Owner/Agent/Contractor(circle one)Date: Page 2 of 2 MASON COUNTY COMMUNITY SERVICES Permit No: zutQzl O--()p Ip PERMIT ASSISTANCE CENTER: •BUILDING.PLANNING •PUBLIC HEALTH•FIRE MARSHAL 615 W.Alder Street,Shelton,WA 98584 � _ Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone 1\r-D r '1 Y'/ .D Belfair:(360)275-4467•Phone Elma:(360)482-5269 JUL 13 20 BUILDING PERMIT APPLICATION 615 W.Alder Street PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: : r'N sexy- 0,416�rlq NAME: D3 *R :.rule- / 0,yva yvuh/c, MAILING ADDRESS: z Z/ r--_ F3GL.s?ivT,�ft� ; MAILING ADDRESS: I11!7 1.jusrl RD CITY: v14r,nw4 STATE: )E) ZIP: 2VSg CITY: Ci4e-dai-4s STATE: U1A ZIP: 11?£36 3L PHONE 3&0 -. 4fcj1 - Uiycj PHONE: -;ti CELL: PHONE#2: iav 00 - Z - 3: s 01"y'n EMAIL : /YI1srF� D1 y.� �it�A�� EMAIL: -�rts�gr�3,g �,,�r /J� '--5 c"Gm>4i� C��rn L&I REG EXP. PRIMARY CONTACT: OWNER CONTRACTOR❑ OTHER❑ NAME 15P-0-:N0Pr VM649AI EMAIL &( e? fv1'l�t4ii.(q-n MAILING,ADDRESS 5r4r111E 46 CITY STATE ZIP PHONE 34v t ) Lf o I—oi-ty CELL PARCEL INFORMATION• PARCEL NUMBER(12 Digit Number) 3 2/Z 7 —S 3 - 000 y j ZONING LEGAL DESCRIPTION(Abbreviated) 1.a"% 1?9" ek IAA- ZIAVAIG4�r DW f FIRE DISTRICT SITE ADDRESS .3.36 E , ��-Q;/��,2 �Qt✓- CITY Cvl�eL-rM� DIRECTIONS TO SITE ADDRESS IS THE PROJECT WITHIN 300 FT OF SLOPE(S) GREATER THAN 14%: YES❑ NO X IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apph•): SALTWATER❑ LAKE ❑ RIVER/CREEK ❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑ TYPE OF WORK: NEW 9 ADDITION ❑ ALTERATION ❑ REPAIR ❑ OTHER ❑ USE OF STRUCTURE(Residence,Garage,Conunerc•ial Bldg,Etc.) IS USE: PRIMARY'® SEASONAL ❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS 2- HEATED STRUCTURE? YES (YiholeBldg) X YES (Part(s)ojBldg) ❑ NO ❑ DESCRIBE WORK /V ktt,' /ylft*ntuF> �ia ,t,�rnF SOUARE FOOTAGE: (proposed) 1ST FLOOR/Z-96 sq. ft. 2ND FLOOR sq. ft. 3RD FLOOR sq. ft. BASEMENT sq. ft. DECK sq. ft. COVERED DECK sq. ft. STORAGE sq. ft. OTHER sq. ft. GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq. ft. Attached❑ Detached❑ MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* MAKE 1101Qs%?=N Y'Tvy MODEL_ YEAR ZOZ,O LENGTH_�A8/ WIDTH_ BEDROOMS 3 BATHS Z, f SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW ❑ EXISTING ❑ 'LUMBING IN STRUCTURE? YES NO ❑ If yes, attach completed Water Adequacy Form PERIMETER/FOUNDATION DRAINS PROPOSED? YES ❑ NOR EXISTING SQ.FT. EXISTING BEDROOMS PROPOSED BEDROOMS _ TOTAL BEDROOMS Z► 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 intPrAct ran.mi„„«,;,