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Box 186, Shelton, 9858 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 VNO-Te-" C_Lxlve-Yr Company Name Mnuhn avNell C Mailing Address 1 193 1&1. Vdxj+n, A%'rpof-+ 1p-a Mailing Address IUSZ% v cl 1, s'-i C- City St-P k kb n State_►^% Zip Code '0 16%'f City Lmv,v wood State eu4 Zip Code 11Ro3-1 Phone Other Ph. Phone 6425)-743- I SS S Other Ph._ Lien/Title Holder Contractor Reg. #oowAJ"F"a5q Exp.__�, E mail address E Mail Address oe.r�peywsciN,t1r•Guru, Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic X- Connect to Water System Name of Water System Well­X—Water System Name of Water System PARCEL INFORMATION - 12 Digit Parcel No. LtZoQ 3 o©cs3o Fire District Legal Description Site Address(Please include street name, street number and city) ISSA cFut '�-A . SW4tt-en Directions to site C,p C -,f d _ Will timber be cut and sold in parcel preparation? Yes/ 3 Is property within 200'of Saltwater t-J C Lake rI O River/Creek �� Pond ► 0 Wetland !J a Seasonal Runoff_L.�Stream o Slopes or Bluffs > 15% %j 0 Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL E]Use of Building 1A0�Se-- Describe Work M 4 Jib Ae r krXA¢A cn*'t 4Q-m,m2- No. of Bedrooms W IA No. of Bathrooms hi.j%A Square Footage- 1 st Floor 12$10 sF 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq. ft. 1 Z9 O S5 Garage - Attached Detached Carport — = Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. --''� No. of Bedrooms No. of Bathrooms Type of Heat urchase Price$ Replacement Unit? Yes/No I me 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 parry 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 CO INUATI N OF WORK IS BY MEANS OF A PROGRESS INSPECTION. 1 X Date: 5 q 1 Owner/Owners Re esentativ factor , ndicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: JYCCO� Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection _ Plan Review Fee EH Review Fee Plumbing & Base Fee Planning Review Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee _ Violation Fee Pre-Paid at Submittal _ Valuation $ TOTAL FEES r1j CONCRETE MECHANICAL MANUFACTURED HOME - C 0 - __.---1 C) Dat B e y < Footings/Setbacks Ribbons Gas Piping IT! cc) Interior Date By Interior'Date By Date By X to)k Exterior Date BY Exterior-Date By Set-up 00 Point Load I Isolated Footings INSULAWN Date By e By BG I SLAB INSULATION m Dat Date By FIRE DEPARTMENT z Foundation Walls Floors Date By Date By Data By DECKS FRAMING Walls Date By Date By po)/( Date By PROPANE TANKS Vault Date By PLUMBING Date By OTHER Groundwork Attic Date Y Date By Type- Date By D.W.1v DRYWALL Type. Int.Brace Wall Date BY Dalp By Date BY r (D FINAL INSPECTION m Cn (D Water Line Fire Separation CD Date By Date By Date By C) Pass Or Request Inspect. 0 C) 5 TypegtInsp. Fail Date Date Done By Comme is -Ph 4�6 e qlvl I( q�jlb) it t4k 00 0 _0 W 0 Lv 0 47 0 1 0 L1 P011- 901 1-011*1 1,16� 0 0 3 .......... (D 0 ------------_-_-_------ MASON COUNTY PERWr V) 1 — BUILDING PERMIT APPLICATION botAls 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 Ko-rw-i C.lvg_r Company Name C Mailing Address Mailing Address IL9521 Hwv Clot, Sd,,� _ C City S%-F IA-e State_ Zip Code 1116931 City ",Avkwaod State t4;A Zip Code °lRo3-1 Phone LIZ'7- 92.9-1 Other Ph. Phone (Af25)-743- 1 SS S Other Ph. Lien/Title Holder Contractor Reg. # T0WnJCRF n9gL-T Exp. U 1 I I E mail address E Mail Address -coy-.I Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic X- Connect to Water System Name of Water System Well__X__Water System Name of Water System ` PARCEL INFORMATION - 12 Digit Parcel No. LtZ•o®3 - -X% - 0003® Fire District Legal Description Site Address(Please include street name, street number and city) 158 3 W. 'Dvhv, .A:cp-,- * -A . SWL%.en Directions to site �Q Q- �'� � d Will timber be cut and sold in parcel preparation?Yes/ o Is property within 200'of Saltwater rJ a Lake River/Creek hj0 Pond ►Jo Wetland 1J a Seasonal Runoff__jLd Stream to Slopes or Bluffs > 15% PJ V Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑ Use of Building 1AaY5e_ ?)0L_*1('to Describe Work 32`u'ta' Ae LAMA cat mmvne SAO-4,YN No. of Bedrooms PJ IA No. of Bathrooms— t I A Square Footage- 1 st Floor n810 sF 2nd Floor 3rd Floor Basement Deck Covered Deck Other Sq.ft. Garage - Attached Detached Carport = Detached MANUFACTURED HOME INFORMATION - Make Model Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Type of Heat - urchase Price$ Replacement Unit? Yes/No I me 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 parry 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 CO INUATI N OF WORK IS BY MEANS OF A PROGRESS INSPECTION. x VJ16 uvAA Date- 5 q 1 Owner/Owners Re esentativ ractor; ndicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by: lea( Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department MI Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing& Base Fee Planning Review Fee Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal Valuation $ TOTAL FEES Name)k0,xean C',--l-1 ex Parcel# 1}2003 3 ` 00 30 BLD# 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 2. '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. 2Common 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. ". .. .. z; Surface Type Length X Width = Area *All dimensions in feet Buildings Lk Q X X = Measurements for buildings are taken at the X _ perimeter of the farthest projections (example: 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 X = Patios/Walks X = X = Any paved, gravel or packed area per definition above table X = Others X F X = �1 ttr e y proprsed XNP k fi��l ltx ruiurface.Ar O NE 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. Owner/ gen Contractor(circle one)Date: X A S 9 5 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 1L Nis Plan jj 40 Town lX ® size Draw A3ath Arrow in CurJe sty C•i6521 F�txratr 99•tarr�t�roost,WA 98037 3t6t a'�se Glxx:k After f3ola�SWe P6adi: Septic and dtaiofisid POST FRAME Bttti_DINGS Everett(425)25t3•at71 Puyallup:(253)s4o-95s2 ( �rttt><;ty dimensions ©ewer Fines Boddie on of propesry aa�av� Administrative Headquarters:(425)743-1555 ��_,y�3fing buildings [ tbadcs of proposed&ercisting buildings D Bodies of water ® nn��ww g T Mx:(ate)742-437e Toll Free: 1-800-824-9552 C�''Proposed building ain road with name ❑Floorplan (D PERIf A BI Ll Conuactor's Lie.#:TOVVNCPF099LT 1-1 Easements Ac B tp proposed building iQp@S&Contmirs(5'increments) Quatity:Qua Future Deperuis On It- Job Name: kftg,"— Job Site Address: 9' d Legal Description: Tax Account# -._ - - ..�... ------------ : : I i £ i t S r } - --------- • i 00 4044 dL AT E ...E t } s , x i t. i t • i _...._....._.. .......... _.... ._ .._i APPROVE , AAAS COUNTY DCD PLANNING , SITE N REQUMD TD.$E ON SITE SUBJET T4 APPROVAL cs BY Dale 1� s re ��0� : b :. ,w LA 14 - - _ ,x _ _ n r � t E � , , --- , AA W Al 1" E c IMMIX i v; pN�CIZ S1GNA`TURl� '� INrrTG f; Do NOT sIGN INCOMPLETE SITE PbANt Copy / Customer has verified and appr Ved the location of the building,orientation of the building to the North,and verifies that all White-Customer Copy White Office utilities.are shown on this dr g in the corr ratio +g — -- A 9 Al X r A f FAD# 71311 -- - --- f 11111111(fill IV ME