HomeMy WebLinkAboutBLD2004-00350 CANCELLED SFR - BLD Permit / Conditions - 5/16/2023 Inspection Line (360)427-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone (360)427-9670, ext. 352
Mason County Bldg. 3 426 W. Cedar P.O. Box 186
Shelton, WA 98584
RESIDENTIAL BUILDING PERMIT BLD2004-00350
OWNER: KENNY MIKLITCH RECEIVED: 3/18/2004
CONTRACTOR: LICENSE: EXP: ISSUED: 4/8/2004
SITE ADDRESS: 271 NE ERICKSON DR BELFAIR EXPIRES: 10/8/2004
PARCEL NUMBER: 223047500050
LEGAL DESCRIPTION: TR 5 OF SURVEY 4/120 271 NE ERICKSON DR TAHUYA
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
SFR Old Belfair Highway to Bear Creed-Dewatto Road, 7 miles to address, third
driveway on right
General Information Construction & Occupancy Info Square Footage Information
No. of Bedrooms: 2 f V
Type of Use: SF Insp, Area. OT No. of Bathrooms: 2 O o Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 2 Building:2,560
Valuation: Building Height: 30 cc. s: Prima Basement: Cov. Deck 400
Manufactured Home Information t c nfor n Shoreline& Planning Information
Water Body: Cat II wetland
Make: Length: Ft. ke
t: 2 Ft. Shoreline: 100.0 Ft. SEPA?: Unkn
15. Slope: Ft. g.: Unknown
Model: Width: Ft. 1: S 3.0 tShoreline DesiYear: Serial No.: 2: 07.0 Ft. Comp. Plan Desig.. Rural
Plumbing Fixtures Nlwl�echanical Fixtures FEES
Type Qty. Qty. Type By Date Amount Receipt
Dishwasher 1 Exhaust Hood 1 Plan Check Fee JRN 3/18/2004 $926.22 612004
Hosebibs 4 Furnace<100K 1 Planning Review Fee JRN 3/18/2004 $155.00 B12004
Kitchen Sink 1 Gas Outlets 1 Building State Fee JRN 3/31/2004 $4.50 B12004
Laundry Tray 1 Ventilation Fan 3 Building Permit Fee JRN 3/31/2004$1,424.95 Is1zoo4
Lavatories 2 Heat Pump 1 Plumbing Fee JRN 3/31/2004 $77.00 B12004
Water Closets (Toilets) 2 Dryer Vent 1 Plumbing Base Fee JRN 3/31/2004 $20.00 1312004
Water Heaters 1 Mechanical Fee JRN 3/31/2004 $75.75 612004
Bath Tubs 2 Mechanical Base Fee JRN 3/31/2004 $23.50 61MN
Clothes Washer 1 EH Plan Review ADR 4/5/2004 $75.00 B12004
Total $2,781.92
BLD2004-00350 Please refer to the following pages for conditions of this permit. 1 of 4
CASE NOTES FOR
B LD2004-00360
CONDITIONS FOR
B LD2004-00360
1) A site inspection by planning staff is required to verify wetland setbacks prior to approval to pour foundation. Please contact Rick Mraz at (360)
4(27-9n exf��77 to schedule the inspection.
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2 Approved per dimensions and setbacks on submitted site Ian. X W110
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3) Temporary erosion control measures must be implemented to prevent water quajttydegradation of adjacent waters or wetlands. Silt fencing must be
installed and maintained until upland vegetation has become established. X L
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4) All 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
xDepar—t—ent prior to any further inspections being performed or approvals granted.
5) In accordance with the Uniform Building Code, all sites shall have approved numbers or addresses located in such a position as to be plainly visible and
legible from the street or road fronting the property. Mason County Building Department requires that this be completed prior to calling for any site
inspections. A re-inspection fee based on rates as adopted by the jurisdiction and the Uniform Building Code will be assessed if the owner and/or
contractor fail post the address on site prior to requesting inspections.
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6) The plan review check list and corrections, along with the Energy Compliance Worksheet (when applicable) are part of the approved plans and must
remain thereto. It is the responsibility of the applicant to make the 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
ins tions.
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7) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X 2,xq '
8) The "approved" plot plan is required to be on-site for inspection purposes. If an inspection is requested and the "approved" plot plan is not 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 shall be collected by
the RuUding Department prior to any further inspections being performed or approvals granted.
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BLD2004-00350 Please refer to the following pages for conditions of this permit. 2 of 4
9) All construction must meet or exceed all local ordinances and the 1997 Uniform Building Code 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
occupari y v�o Id result in permit revocation.
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10) Propos structure or portions thereof, must maintain a 5' separation distance between adjacent structures and that furthest projection.
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11) All changes to "approved" building plans that effect compliance with the Uniform Codes as amended and adopted, or any other Mason County
ordinanc regulation, must be reviewed and approved by Mason County prior to construction.
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12) The construction of the permitted project is subject to inspections by the Mason County Building Department. All construction must be in conformance
with the Uniform Codes as amended and adopted by Mason County. Any corrections, changes or alterations required by a Mason County Building
Inspecto hall Pe made prior to requesting additional inspections.
X 1, ,1,
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13) All property lines shall be clearly identified at the time of foundation inspection. X
14) All building permits shall have a final inspection performed and approved by the 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
X n-compt�nt w�iith Mason County ordinances and building regulations.
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15) All permits expire 180 days after permit issuance, or 180 days after the last inspection activity is performed. The Building Official may extend the time
for action for a period not exceeding 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the
permit h�de��e prevented action from being taken. No more than one extension may be granted.
X
16) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
connec�rs,�ndflashing. Install metal connectors approved for contact with the new types of pressure treated material.
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17) Fuel piping shall be inspected after the installation of fuel piping is complete, and before the attachment of fixtures, appliances, or shut-off valves. At
the time of inspection the test pressure shall be no less than 10 psi held for no less than 15 minutes. Appliances to be attached to the fuel piping
X stem all n o be used until the final inspection has been performed and approved by a Mason County building inspector.
BLD2004-00350 Please refer to the following pages for conditions of this permit. 3 of 4
This permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended for a period of 180 days at any time after
work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied. Proof of
continuation of work is by means of progress inspection.The owner or the agent on the owners behalf,represents that the information provided is accurate and grants employees of
Mason County access to the apoveescr ed pro e a d s ruct re for review and inspection.
OWNER OR AGENT: -- G� �� �_ DATE:
BLD2004-00350 Please refer to the following pages for conditions of this permit. 4 of 4 .
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CONCRETE MECHANICAL MANUFACTURED HOME
0 Date By
Footings I Setbacks Gas Piping
Ribbons
o Interior Date By Interior•Date By Date By
Cn
Exterior Date By Exterior-Date B Set-up
Point Load I Isolated Footings INSULATION Date By
Date By BG/SLAB INSULATION
Date By FIRE DEPARTMENT
Foundation Walls Floors Dale By
Date By Data By DECKS
FRAMING Walls Date By
Date By Data By PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attic
Date By Date By Type=
Date By
D.W.v DRYWALL Type,
Int Brace Wall Date By
Dale By Date By
FINAL INSPECTION
Water Line Fire Seperation
Date By Date By Dale By
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o MASON
COUNTY (360)427-9670 Shelton eXt.352 '-
DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfalf 2Xf. 35
BUILDING•PLANNING•FIRE MARSHAL (360) 482-5269 Elma ext. 352
Inspection Hotline (360)427-7262
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Mason County Bldg. 8, 615 West Alder Street www.co.mason.Wa.us
r,rr, gssa �; Shelton, WA 9$584
CORRECTIONANSPECTION
REPORT
PERMIT/CASE NUMBER;
ADDRESS/LOCATION: 7�7 1 /V(' e f;(ce ri&j
FINDINGS:
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77
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Items listed above must be corrected to gain compliance.
❑ THIS IS NOT A COMPLETE INSPECTION
❑ This structure has been inspected by Mason County Building Department and the items listed
above are in VIOLATION of Mason County laws and/or ordinances.
❑ Call for re-inspection when corrections are made before proceeding with any further work.
❑ Make corrections, items will be checked on the next inspection.
❑ OK to
Date: .! Fontact our office regarding possible
Department: ' ( '; amage Incurred by recent
Inspector: �r'' " !i ^'`"'' an made"disasters.Thls is NOT a
N NOTICE.
D►6'NOT REMOVE THIS TAG
MCC14.12
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MASON COUNTY
BUILDING 111 426 W. CEDAR
SHELTON, WASHINGTON 98584
(360) 427-9670
CORRECTION NOTICE
Job Location A'l1%SClio zZz
This structure has been inspected by Mason County Building Department
and the following VIOLATION of County Laws and Ordinances has been
found: Items listed below must be corrected to gain compliance
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You are hereby notified that the above corrections shall be made
BEFORE PROCEEDING WITH ANY FURTHER WORK
❑ Call for re-inspection when corrections are made before continuing ❑ please contact.our office
❑ Make corrections, items will be checked on next inspection regarding possible structural
❑ OK to damage incurred by recent
"naturallman made"
❑This is/not a complete inspection disasters.This is NOTa
Date ✓ -L� Department CORRECTION NOTICE
Inspector r�
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Asor� aoayrf MASON COUNTY (360)427-9670 Shelton ext.352
- DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext. 352
BUILDING•PLANNING•FIRE MARSHAL (360)482-5269 Elma ext. 352
Inspection Hotline (360)427-7262
- s Mason County Bldg. 8, 615 West Alder Street
1854 Shelton, WA 98584 www.co.mason.wa.us
CORRECTION/INSPECTION REPORT
PERMIT/CASE NUMBER:
ADDRESS/LOCATION: �1
FINDINGS
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icy
f _ .• �`4 rr'� T4,r 6VO t`''� E3 W �}ti� r ''O
Items listed above must be corrected to gain compliance.
❑ THIS IS NOT A COMPLETE INSPECTION
❑ This structure has been inspected by Mason County Building Department and the items listed
above are in VIOLATION of Mason County laws and/or ordinances.
❑ Call for re-inspection when corrections are made before proceeding with any further work.
❑ Make corrections, items will be checked on the next inspection.
❑ OK to
Date: �/.��f,. ❑ Please contact our office regarding possible
Department:_.` z f,_ `y structural damage incurred by recent
Inspector:� `,,+� : � "natural/man made"disasters.This is NOT a
CORRECTION NOTICE.
E
DO NOT REMOVE THIS TAG
MCC14.12
Aso cooyr MASON COUNTY (360) 427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfair ext. 352
BUILDING• PLANNING•FIRE MARSHAL (360) 482-5269 Elma ext. 352
Inspection Hotline (360)427-7262
Mason County Bldg. 8, 615 West Alder Street
Shelton, WA 98584 www.co.masonma.us
CORRECTION/INSPECTION REPORT
PERMIT/CASE NUMBER: �oa oo Ja
ADDRESS/LOCATION: 2:7LS
FINDINGS:
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3 S a2 oNS'
EC
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r� layf t nVATr- �-J7� /f,-Jo t'Ws tkr-
Items listed above must be corrected to lain compliance.
❑ THIS IS NOT A COMPLETE INSPECTION
❑ This structure has been inspected by Mason County Building Department and the items listed
above are in VIOLATION of Mason County laws and/or ordinances.
❑ Call for re-inspection when corrections are made before proceeding with any further work.
❑ Make corrections, items will be checked on the next inspection.
❑ OK to
Date: ❑ Please contact our office regarding possible
Departm ( _ structural damage incurred by recent
Inspector: "natural/man made"disasters.This is NOT a
CORRECTION NOTICE.
D OT REMOVE THIS TAG
MCC14.12
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MASON COUNTY COMMUNITY SERVICES Permit No: l�Z
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
Belfair:(360)275-4467•Phone Etme:(360)482-5269
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015 K-S root,Bhofton,WA 83584
Phone Shelton 300 4T.7-9B xt.352•Fax (360)427-7799 Phone
Beftntr."( 67•Phone Elmer(300)482-5209
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DEPARTMENT OF COMMUNITY DEVELOPMENT
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DEPARTMENT OF COMMUNITY DEVE�`. PMEN (360)275-4467 Belfair ext. 352
BUILDING•PLANNING o FIRE MARSHAL 6 $60) 482-5269 Elma ext. 352
Inspection Hotline (360)427-7262
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1854 Shelton, WA 98584 wwwxo.mason.wams
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Washington State Department of
Labor & Industries
Your jobsite for permit number EP2906204 was inspected 9/27/2017 by CLAY MICHEAU.
The results of inspection are listed below:
Inspections:
Inspection Date I Inspection Result Inspection Comment
9/27/2017 IFinals,Single Family [Approved Complete
The following corrections were written on this inspection today.
The following corrections were marked completed on this inspection today.
You can view all inspection information on this permit online at Labor and Industries,electronic permit
and inspection system.Additional fees may be assessed and will not appear until they are processed by
our support team.
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MASON COUNTY PERMIT NO. 6W Zovy -Do_35Q
DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING•PLANNING•FIRE MARSHAL
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason County Bldg.111,426 West Cedar Street (360)275-4467 Belfair ext.352
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615 W. Alder Street
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MASON COUNTY PERMIT NO. 0 ZOyq -DO-3 e
DEPARTMENT OF COMMUNITY DF-VELOPMENT
BUILDING•PLANNING•FIRE MARSHAL
' AN WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason County Bldg. III,426 West Cedar Street (360)275-4467 Belfair ext.352
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MASON COUNTY PERMIT NO. -&V Zovq -00350
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)275-4467 Belfair ext.352
4 (360)482-5269 Elma ext.352
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DEPARTMENT OF COMMUNITY DEVELOPMENT
BUILDING• PLANNING• FIRE MARSHAL
WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason Counh/I�Jdg. III,426 West Cedar Street (360)275-4467 Belfair ext.352
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DEPARTMENT OF COMMUNITY DEVELOPMENT
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WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason Counh/I�Jdg. 111,426 West Cedar Street (360)275-4467 Belfair ext.352
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MASON COUNTY (350) 427-9570 Shalton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (HO) 275-4467 Belfair ext 352
BUILDING+ PL ,tvNIP,G• FIRE MARSHAL ,3K, 482-5259 Elma ext 352
I % ; Inspection Hotline (360) 427-7262
Mason County Bldg. 8, 615 West Alder Street
Shelton, WA 98584 www-co.masonma.us
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MASON COUNTY (360) 427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfair ext. 352
BUILDING•PLANNING• FIRE MARSHAL (360) 482-52c,9 Elma ext 352
t Inspection Hotline (360) 427-7262
Mason County Bldg. 3, 615West Alder Street
�IBia Shelton, WA 98584 www.co.mason.wa.us
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RECEIVED
APR 0 7 2021
615 W. Alder Street
COD
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 DD2004-00350 NEW SINGLE FAMILY RESIDENCE
PROJECT DESCRIPTION: SFR ISSUED: 04/08/2004
SITE ADDRESS: 271 NE ERICKSON DR BELFAIR
EXPIRES: 10/04/2021
PARCEL: 223047500050
APPLICANT: KENNY MIKLITCH OWNER:
123 XXX
XX,XX 00000
FEES: Paid Due
Plan Check Fee $926.22 $0.00
Plan Check Fee $926.22 $0.00
Plumbing Fee $77.00 $0.00
Building Permit Fee $1,424.95 $0.00
Building Permit Fee $1,424.95 $0.00
Building Permit Fee $1,424.95 $0.00
EH Plan Review $75.00 $0.00
Mechanical Fee $75.75 $0.00
Plumbing Base Fee $20.00 $0.00
Planning Review Fee $155.00 $0.00
Planning Review Fee $155.00 $0.00
Planning Review Fee $155.00 $0.00
Building State Fee $4.50 $0.00
Mechanical Base Fee $23.50 $0.00
Totals : $6,868.04 $0.00
REQUIRED INSPECTIONS
Permit Extension BLD-Final Inspection
Final Inspection-Failed Progress Inspection
Printed by:Corey Bennett on:04/08/2021 11:40 AM
Page 1 of 2
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
NEW SINGLE FAMILY RESIDENCE BLD2004-00350
Footing Inspection
Foundation Wall Inspection
Framing/Plumbing/Mechanical
Insulation Inspection
Wallboard Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
Progress Inspection
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:
Contractor or Authorized Agent: Date:
Printed by:Corey Bennett on:04/08/2021 11:40 AM Page 2 of 2
MASON COUNTY 615 W.Alder St.Bldg 8,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 352
COMMUNITY SERVICES
BELFAIR:360-275-4467,EXT 352
Budding,Planning.Environmental Health,Community Health ELMA:360482-5269,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/bld-inspection.php
Permit Number BLD2004-00350 Date Issued 04/08/2004 Issued By
Project SFR co
Site Address 271 NE ERICKSON DR 1
Applicant KENNY MIKLITCH CANCELLEDContractorContractor Phone 2015
Primary Code UPC IBC,IRC,IFC,IEC,IMC,& Type
Permit Type NEW SINGLE FAMILY RESIDENCE 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
Department Building Official: Community Services Designee
Concrete Setbacks Slab
Footing Perimeter C11pti iS;,,A Li, Point load Footing
Footing Interior Footing Decks/Porches
Foundation Stem Walls Oil b56 OA-1 S Other
Rough-In Groundwork Plumbing Framing -Cyz-_
Groundwork Mechanical Plumbing
Groundwork Gas Pipe Mechanical
Gas Piping Shear Wall Nailing
Underfloor
Other
Insulation Slab Ceiling
Floor Vaulted Ceiling
Walls n1 q,kp -'tom Vapor Barrier
Other W(.�oGRA -1117
Wallboard Interior Wall Brace Panels Fire Walls
Nailing
Other
Final Building
Manufactured Setbacks Setup
Home
Concrete Foot/Runners Final
Other
g h'0 ky
oy Est�z� c-E3g
MASON COUNTY PERMIT NO. BLD
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584 UU O
Shelton(360)427-9670 Belfair(360)275-4467 Elma(360)482-5269 Seattle(206)464-6968
On the Web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
✓n �
Owner AA `�- 9116MI4 Contractor Name r
Mailing Address all >{ Mailing Address '7/ i C' �, ,�Y�) I►�
City State i A Zip Code 7 City- $e 1 ta;r T State IA-Zip Code G ��sr
Phone L__j Other Ph. (__j Phone ( lipo) 77---M44C Other Ph. C__j
Lien/Title Holder Contractor Reg.# _ Exp.
E-mail Address E-mail Address
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic Connect to Sewer
System_Name of Sewer System Well Water System
Name of Water System
PARCEL INFORMATION- 12 digit Tax Parcel No. ,j_ ,,; / . , /,,�.,�,; ,f� , Fire District
Legal Description 4 S -,,+ 14/1? P+✓t
Site Address (Please include street name,street number and city) _�L7l AX Zi W 4-sw nV
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No)_ /11
Lake River/Creek Pond Wetland Seasonal Runoff Stream
Slopes or Bluffs
PERMANENT RESIDENCE SEASONAL RESIDENCE❑
TYPE OF JOB- New Add Alt Repair Other Use of Building
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action? (Yes/No) !�
Describe Work
No.of Bedrooms_No. of Bathrooms SQUARE FOOTAGE 1st Floor 2nd Floo /�, Lei-
3rd Floor Loft Basement Deck Other0l)4( q.ft. Q61Y ' 40
Garage Attached Detached Carport Attached I Detached
MOBILE HOME INFORMATION - Make Model Model Year
Length Width Serial No. No.of Bedrooms No.of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? (Yes/No)
Installer Name Certification No.
NOTICE:THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and inspection
of this project.Owner/Builder acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgment
of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the ordi- contractor in the State of Washington and that I am aware of the ordinance
nance requirements for which this permit is issued and that all work will be requirements regulating the work for which this permit is issued and all
done in conformance therewith. No changes shall be made without first work shall be done in conformance therewith.No changes shall be made
obtaining approval. without first obtaining approval.
X I Date 3 ' X Date
OR OF 'BEYOND THIS POINT
X
Accepted by Date Submittal Amount Due Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIEE :. :,., u; CO1+1>I?M) pl+ DES
Building Department 0 3�
Occ Grou Type Constr.
Planning De rtment
Environmental Health Department
Public Works Department
Fire Marshal
Valuation
i FEES
Building Permit Fee L Site Inspection
Plan Review Fee QG `a a EH Review Fee
Plumbing&Base Fee Planning Review Fee
Mechanical& Base Fee g- r. Other
Wood/Gas/Pellet Stove Fee State Fee ( 60
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES
PERMIT NO.:
MASON COUNTY
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 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner �h�, v�i U i C� Contractor Name
Mailing Address all hjy7l i ' 1� -W �; Mailing Address _9 1 N L -R1(' ,r S b" ZVI&
City -�e tru,r State,. Zip Code City .: � State�_ Zip Code 91'z;Z�
Phone(, 7Z-� ,/DOther Ph.(----) — Ph.( ) Other Ph.(
Lien/Title Holder Contractor Reg. #
Address - Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No. t / ? S / (�QSA y- _ Fire District
Legal Description ?'r 171 SU /-//`2 4-.0�.I elf'L 4,1` Z 3 wZ II!
Site Address (Please include street name,street number and city) ��2°7if A),6 Zj I&
Directions to site p
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland_Seasonal Runoff_Stream
Slopes or Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
l Location of Fixtures/Units 1 st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Elec
Type of Fixture No.of Fixtures Fees LPG Natural Gas Heatpumpctri
4_
Toilets `' Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer Gas Outlets
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other t Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
Xftkjj'�rV. Date &—Oq X Date
r _(t
FOR OFFICIAL
E BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
FJ A1iTtVEENTAE iRE1/fEW .APIPROV p .DENI ED.
CONDITION sCODES
`
Building Department
Occ Group Type Constr.
Planning Department
Other
Other
FEES
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES