HomeMy WebLinkAboutBLD2007-01647 Revised SFR Final - BLD Permit / Conditions - 12/22/2009 Request To Revise An Approved Plan
Permit Number: BLD200 7 -D l(A7 Name
Parcel Number Zl I - 75- - 9DOZ0 Phone Number daytime (AOU �'3Q3 la�11
Project Address j- 5�<« —Z)f Mailing Address
Please provide a complete,detailed description of the proposed revisions to the approved plans:
o
Are two sets of the revised plans or addendum indicating the changes included? El"Yes ❑ No
Are the approved site plans included? ❑ Yes [.a'No
Are the revisions clearly and accurately identified on the plans or addendum? L7"'Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ErNo
If Yes,Has the engineer or architect approved this revision? ❑ Yes o No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
(Note:No structural changes to a"desiped"plan will be approved without the written consent of the engineer and/or architect of record-)
Does the proposed revision modify the footprint or location of the structure? frYes ❑ No
If Yes,Is a revised site plan,with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:_ �3o—t p —.s;A& I
Applicant's signatureAWA, ��—,-r_> L Date: La Z
Office Use Only Rec:ei ed by: Yr1�Ft L
Date Sent Assigned To Approved By Date
Original Valuation: $
L (i Additional Valuation: $
❑ P. i 1(at ter ,d VJ v l - P rr vL t —X$_lam $ �? _e� .
q.Ft. x$ $
20 E.H. L/lam not fttC( Total New Valuation $
Additional Fees:
Additional Planning Dept. $
Additional Plan Review $ . 4( Q
Ad 'tional Conditions./-Comments: Additional Building Permit $ (o3'—
Additional Plumbing $
L Ll Additional Mechanical $
Additional E.H.Dept. $
Other $
Zo
Total Amount Due: $
Amount To Be Paid Up-Front$
�s—
Inspection Line(360)427-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427-9670,ext.352
Mason County Bldg. III 426 W. Cedar P.O. Box 186
Not Shelton,WA 98584
RESIDENTIAL BUILDING PERMIT BLD2007-01647
OWNER: NEIL RICKER
CONTRACTOR: ZECH BUILDERS 360-275-8127 LICENSE: ZECHB055MP EXP: 7/17/2008 RECEIVED: 9/14/2007
SITE ADDRESS: 148 E PIRATES DR GRAPEVIEW ISSUED: 2/12/2008EXPIRES: 8/12/2008
PARCEL NUMBER: 121187590020
LEGAL DESCRIPTION: TRACT 2 OF GOVT LOT 1 &TAX 1433*TRACT 3 OF SURVEY 7/3 & SP#571
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW SFR HWY 3 TO RIGHT ON GRAPEVIEW RD TO RIGHT ON E LOMBARD RD TO
RIGHT ON E PIRATES DR TO RIGHT ON MINER RD TO END OF ROAD AND
SITE ON RIGHT
General Information Construction&Occupancy Information Square Footage Information
No. of Bedrooms: 2 Type of Constr.: VB
Type of Use: SF Insp.Area: No. of Bathrooms: 3 Occ. Group: R3 Lot Size: Deck: 710
Type of Work: NEW Fire Dist.: 3 No. of Stories: 2 Occ. Load: Building:1,630
Valuation: Building Height: 26 Occ. Status: Seasonal Basement:391
Manufactured Home Information Setback Information Shoreline&Planning Information
Make: Length: Ft. Front: N 307.0 Ft. Shoreline: 50.0 Ft. Water Body: CASE INLET
Rear: S 50.0 Ft. Slope: Ft. SEPA?: Unkn
Model: Width: Ft. Shoreline Desig.: bWt an
Side 1: E 8.0 Ft.
Year: Serial No.: Side 2: W 8.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Tyne By Date Amount Receipt
Hosebibs 2 Exhaust Hood 1 Plan Check Fee KS 9/14/2007 $802.46 S12007000
Kitchen Sink 1 Gas Outlets 2 Planning Review Fee KS 9/14/2007 $170.00 S12007000
Lavatories 3 Propane Tank 1 Fire Warden Review DHS 9/19/2007 $64.00 S22bb8bbb
Showers 1 Ventilation Fan 3 Geotechnical Asses. Report BKD 10/8/2007 $167.43 S22bb8bbb
Water Closets (Toilets) 3 Ventilation System 1 Building State Fee MAL 10/29/200 $4.50 S22bb8bbb
Water Heaters 1 Dryer Vent 1 Building Permit Fee MAL 10/29/200 $1,234.55 § bb8bbb
Bath Tubs 1 Boiler 1 Mechanical Fee MAL 10/29/200 $131.70 S22008000
Clothes Washer 1 Mechanical Base Fee- MAL 10/29/200 $25.30 S22008000
Clothes Washer 1 Plumbing Fee MAL 10/29/200 $97.90 s22oos000
Plumbing Base Fee MAL 10/29/200 $22.00 S22bb8000
Geotechnical Asses.Report BKD 1/22/2008 $166.94 S22008000
EH Plan Review TW 2/1/2008 $75.00 S22008000
Total $2,961.78
BLD2007-01647 Please refer to the following pages for conditions of this permit. 1 of 6
CASE NOTES FOR
BLD2007-01647
CONDITIONS FOR
BLD2007-01647
1) Temporary erosion control measures must be implemented to prevent water quality degradation of adjacent waters or wetlands. Silt fencing must be
installed and maintained until upland vegetation has become established.
All di�>Mr s shall be stabilized with mulch and seeding if they will remain unworked for more thn 14 days.
X
2) The approval of this project is subject to the recommendations and specifications outlined in the attached geotechnical re EPT the cutting of
trees in the buffer is not approved. The geotechnical report shall remain attached to the approved building plans. X
3) Thee cknowledges that this development was sited such that further shore protection measures will not be required for protection of the facility.
X�
4) 1. Perform excavation, land clearing, and site preparation work during dry weather.
2. Install silt fencing around the work area to prevent erosion and additional siltation of both the stream and shoreline.
3. Minimize the amount of erodible soils to the maximum extent feasible.
5. Check all equipment daily for leaks. Refueling and lubrication of equipment should occur off site. Do not store any fuel, lubricants, chemicals, or
hazardous substances outside overnight within the project area.
6. D� 4y chemicals when there is a possibility of rain.
X
5) All drains shall be directed away from the bluff face. Roof run-off shall be directed into a drywell system (see Geo Report)located to the rear(north) end of
the property.
X
6) An orange contruction fence shall be installed at the clearing limits (no closer to the water than 55 feet) prioir to any clearing or grading and shall remian
inpl,� ruction is complete.
X
7) The"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, 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
Build agent prior to any further inspections being performed or approvals granted.
X A�
BLD2007-01647 Please referto the following pages for conditions of this permit. 2 of 6
8), By definition, propane tanks and heatpumps are structures, which must meet setback conditions. Please check your"Approved Site Plan"to ensure
these structures m t the setback conditions listed.
X
9) All changes to"approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance r lation, must be reviewed and approved by Mason County prior to construction.
X �J�j
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10) Landings and stairs must meet the same setback conditions as any permitted structure;and, must be shown on your site plan. Please check your
"Approv Ian"to ensure these structures are shown and meet the setback conditions listed.
X �
11) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
connec r cJ�hashing. Install metal connectors approved for contact with the new types of pressure treated material.
X /�
12) 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. n addition, a re-inspection fee(refer to current fee schedule, minimum 1 hour)will be charged and must be collected by the Building
Depart to any further inspections being performed or approvals granted.
X
13) Ow ne a is onsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
X
14) The plan review check list and corrections 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
remov oo d documents will result in failure of required building inspections.
X
15) Any changes in proposed construction shall be reviewed by the engineer or architect of record and submitted in writing to the Mason County Building
Department prior to construction. All engineering and/or architectural documents are a part of the approved set of plans and shall remain attached
thereto. If documents are removed, approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be
charge collected by the Building Department prior to any further inspections being performed or approvals granted.
X
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16) All construction must meet or exceed all local ordinances and 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
per
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17) The placement of small propane tanks are not normally subject to a permit review by the Planning Department; however, propane tanks are subject to
Planning Department regulations. Such regulations primarily consist of setbacks from shorelines and features considered to be critical areas (streams,
wetlands, slopes, etc.) If you think such fe a is n or nearby your property, please contact the Planning Department so that exact setback
requirements can be determined. X
BLD2007-01647 Please referto the following pages for conditions ofthis permit. 3 of 6
18) 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 system shall
not be use ' hq�fnal inspection has been performed and approved by a Mason County building inspector.
f X ;`
19) All property lines shall be clearly identified at the time of foundation inspection. X
20) 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 non-compliant with
Maso0ogonances and building regulations.
X
21) 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
hold ery e nted action from being taken. No more than one extension may be granted.
X
22) Washington State Energy Code Compliance has been approved using the following:
Heat Type: Electric or other fuels, Compliance Method: Prescriptive option IV, Window(Max U-Factor):0.35, Skylight(Max U-Factor):0.58, Doors
(Type/Max U-Factor):0.20 or less, Wall insulation R-21, Floor insulation R-30, Ceiling Insulation R-38, Vault Insulation R-38 (see exception), Slab
Insulation R-10.
Exception: R-30 insulation may be installed, up to 500 sq. ft., in single rafter or joist vaulted ceilings where the distance of the top of the ceiling and the
X d!de,AiA of sheathing is less than 12-inches and there is 1-inch vented airspace above the insulation.
23) Per 2003 IRC-SECTION R905- REQUIREMENTS FOR ROOF COVERINGS- R905.1 Roof covering application. Roof coverings shall be applied in
X cor�celru�e applicable provisions of this section and the manufacturer's installation instructions.
�7
24) Retaining walls needed to support a surcharge��seructures, roads, or to support slopes, shall require a separate building permit and approval prior
to construction of the retaining wall. X
25) Place re must comply with standards set forth per the international codes regarding descending and/or ascending slopes.
X
26) 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 locate 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 proj
X
BLD2007-01647 Please referto the following pages for conditions of this permit. 4 of 6
•27) All propane tanks Tust be installed in accordance with the International Fire Code and all applicable Mason County ordinances. All propane tanks must
meet the in ements and minimum setbacks as listed in the Mason County Fire Marshal's Standards for the Installation of Propane Tanks.
X
28) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X
29) Per 2003 IRC-SECTION 1609-WIND LOADS - 1609.1 Applications. Buildings, structures and parts thereof shall be designed to withstand the
minimum wind loads prescribed herein. Decreases in wind load shall not be made for the effect of shielding by other structures. Per FIGURE 1609
BASI EED (3-SECOND GUST)the wind speed for Mason County is 85 MPH.
X
30) 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
Inspe� made prior to requesting additional inspections.
X
31) Installation of heating equipment in single family residences shall meet the requirements of the current Washington State Energy Code.
The furnace to be installed shall not exceed 150% of the heating and cooling design load. Heating and design load calculations for the purpose of sizing
HVAC systems are required and shall be calculated in accordance with accepted engineering practice, including infiltration and ventilation. Design
calculations shall be available for inspection during the framing inspection.
Warm-air furnaces shall have a minimum efficiency of 78%AFUE or higher or 80% combustion efficiency. All ducts shall be securely fastened and
sealed with welds, skets, mastics (adhesives), mastic-plus-embedded-fabric systems or tapes installed in accordance with manufacturers installation
instruc 'pe is NOT permitted as a sealant on any ducts. Ducts in unheated spaces shall be insulated to R-8.
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32) 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
1-8� The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
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33) The international code requires a fire apparatus access road for every facility, building, or portion of a building that is more than 150'from an approved
access road. Roads are required to meet the minimum Mason County Fire Marshal standards for Fire Apparatus Access Roads up to the point where
such ro with a county maintained public road or to another fire apparatus access road which connects to a county maintained public road.
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34) Mason County uilding code Chapter 14.17.040 and 050 and 060 must be estsblished prior to Final sign-off.
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BLD2007-01647 Please referto the following pages for conditions of this permit. 5 of 6
35) Prior to final approval, al� s disturbed or newly created by construction activities shall be seeded, vegetated or given an equivalent type of
erosion protection. XIV P, _
` 36) Owner/builder assumes all responsibility if drainfield/reserve area is encumbered. X
37) By definition, propane tanks and heatpumps are structures, which must meet setback conditions. Please check your"Approved Site Plan"to ensure
these structures cneet the setback conditions listed.
X
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 anytime 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 a 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 above described prope Vandruct re f ev. and i spection. /
OWN ER OR AGENT: DATE:
BLD2007-01647 Please refer to the following pages for conditions of this permit. 6 of 6
00
o CONCRETE MECHANICAL MANUFACTURED HOME
n
C) Date 9 ��_y —�
o) Footings ISM Gas Piping B Ribbons �^ m
o Interior Date By interior. Date �.O�By�W,/ )ate By l
0 !/�
� Exteror Date�j•/7•L� B Exterior-Date B S•t:� Z
4 INSULATION m
Point Load I Isolated Footings Date By r
BG!SLAB INSULATION
Date By Data By FIRE DEPARTMENT
Foundation Walls Floors Date By
Date Byj� Data By DECKS
F RAM I NG wafts Date By
Date By Data &/. By PROPANE TANKS
PLUMBING vault ]_ J Data
Date Cj/ By
C OTHER
Groundwork Attic Type-
Date By Date By
Data By
n.w.v DRYWALL Type-
Date 2�.� B Int.Brace Wall Date Byo
W
Date By FINAL INSPECTION
fD Water Line Fire Separation N
m
Date By Date By Date _ L 2 �c' By CD
m V
`° Pass or Request Inspect.
s Typq of Insp. Fail Date Date Dane By Comments
CD V
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ACCESS & GRADE INSPECTION PERMIT #: e 5�007 _ MeLk
ADDRESS Z U
INSPECTOR 4-k DATE: L It) --/
DRIVEWAY-,ACCESS
Len the Width: Surface: P ( �-
Size of turn-around:
Condition of shoulders:
Vertical clearance:
- - ) need post at end of driveway with keflective address numbers
GRADE,OF DRIVEWAY %, OF ROAD %
ROAD ACCESS
Length: Width: Surface:
Condition of shoulders:
Vertical clearance:
( ) BURN PERMIT REQUIRED FOR LAND CLEARING FIRE.
( ) LOT INSIDE SMZ, 4X4 FIRES ONLY.
( ) LOT INSIDE UGA, NO OUTDOOR BURNING PERMITTED.
LOT TOO SMALL FOR: BURN PERMITS 4X4 FIRES.
REMARKS C�, c '� l;
(continue remarks on back)
x
art 64 arcA7;ectare
JAY L A Z E R W I TZ 61z6 tzth Ave NE Seattle,WA 98215 1 www.artandarch.net I ph 2o6.524 868o I fax 2o6.527_521S I 1ay@artandarch.net
October 24, 2007
Michael Luke RECEIVED
Mason County Building Department
P.O. Box 186 OCT 26 W,
Shelton, WA 98584 426 W: CEDAR ST:
Re: Ricker residence BLD 2007-01647
148 E. Pirates Drive, Grapeview, WA
Attached are revisions to the current plans:
1. Design criteria for Soils to be 1500psf. See revised footing pads on plan markups (to be
36"x 36", instead of 30"x 30'). Attached are updated calculations and Foundation Plan
revision.
2. I am a Registered Architect in the State of Washington.
3. These plans to comply with 2006 IBC.
I hope this satisfies the initial review questions.
Thank you,
N 4e��
]ay Lazerwitz
=a7LAZERWiTz
ERED
TECT
J
STATE OF WASHINGTOS�
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
J4
October 01 , 2007 PO BOX 1666 Shelton WA 98584
Shelton (360)427-9670
Fax (360)427-8442
NEIL RICKER Elma (360)482-5269
1160 20TH AVE E
SEATTLE WA 98112 Belfair (360)275-4467
Case No.: BLD2007-01647 Parcel No.: 121187590020
Dear Applicant:
Your building permit cannot be approved by Mason County Environmental Health until
the following are completed and turned in:
Please see comments at the end of this letter.
Please call me at (360)427-9670, ext. 554 if you have any questions.
Sincerely,
Trish Woolett
tw@co.mason.wa.us
Environmental Health
Mason County Health Services
Comments: Although the 2 party well was approved. The recorded (auditors file
#1868560) Notice to Future Property Owners of Private 2 Party Water
System, was recorded such that it does not include this lot. In order to
sign off on this portion of your permit you will need a "revised" Notice to
Future Property Owners of Private 2 Party Water System recorded with
Mason County Auditors Office, $40.00. See attached.
10/1/2007 1 of 1 BLD2007-01647
PF MASON COUNTY PERMIT NO.—, Cn J� `-l0
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 Nil-
OnShelton (360) 427-9670• Belfair (360) 275-4467• Elma (360) 482-5269 the web www.co.mason.wa.us
APPLICANT INFORMATIO CONTRACTOR INFORMATION
Owner-Nail 91- 13evey'N Ricker Company Name Zzak Ow' ergs
Mailing Address 1160 A0 h 11vc, C0.r r Mailing Address PO box 51 G
City Seale State WA Zip Code 92112, City Cr roe State—B_Zip Code 9
Phonel-.7,o 6)3; 3-aq 1-1 Other Ph.6x(K 0 5q3- n 78 6 Phone 6() °I ' Other Ph. t, MO-aA �G
Lien/Title Holder Contractor Reg. # CCI1 #40 Exp.
E mail address N L -- i errR C vq Woo, c,OM E Mail Address M Rt1ILQfT-6) VAHKr-
Drivers Lic.# DOB 10 I q99 Drivers Lic.#'El"JtM L y IS J 7 DOB -7 I q g
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic ✓ Existing Septic
Connect to Water System Name of Water System
Well ✓ Water System Name of Water System
PARCEL INFORMATION- 12 Digit Parcel No coo Fire District
Legal Description Tr11+ 3 f u l� 5 I yV c 919 a s ii , ' -# 3(.534q
Site Address (Please include street name, street number and city) 1 - v✓
Directions toasite "'1 . ern - s M Ed
0,CA( ni Z C ti C
Will timber be cut and sod in parcel pre aration?Yes/s,�
Is property within 200'of Saltwater _Lake River/Creek Pond
Wetland Seasonal Runoff__Stream Slopes or Bluffs > 15% ✓
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye
TYPE OF JOB - New_,!Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL
Use of Building �/a cad�� h rrr ra Describe Work
No. of Bedrooms_L No.of Bathrooms A, G Square Footage- 1st Floor f 1 5 C- 2nd Floor 474
3rd Floor / Basement 3'�t Deck -710 Covered Deck /Vfy— Other Sq.ft.
Garage Nix—_ Attached Detached Carport_ yeOv- Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? Yes/No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or pe nt of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further d r th t I am enti I efr a 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 pe n 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 irhformation
provided is accurate and grants em loyees of Mason County access to the above described property and structure for review and inspection.
PROOF O T10N O ORKIS BY M,FANS OF A PROGRESS INSPECTIO y WASO N CO U NT_x/
XM �-�f Date# �r(0 or
Owne wners Representative/Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED D NI D NOTES
Building Department JPINO JQb
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee Z 16 EH Review Fee
Plumbing& Base Fee 7'?-'> 22!t Planning Review Fee
Mechanical & Base fee 1317,,5� 21V!E Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal qil
Valuation $ 1q'L7-Q-7Cf So TOTAL FEES
MASON COUNTY PERMIT NO.
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
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORM N
fflIO
Owner N &✓ r 1 °. 1� Company Name sEr '� CV rs
Mailing Address- I I C,0 0 t C Mailing Address PO aox 5!6
City State �._Zip Code 1'� City l r�o�✓,GU✓ State '01A Zip Code.- r t
Phone 0,003 3 - (11_7 Other Ph.(10( 593 - ?-13L Phone&4 6) LZL- G:SSS Other Ph. b)340 R 'IO
Lien/Title Holder Contractor Reg. # :ZFZCNpx*05 RM P Exp. 9Z17
E mail address /V g -- . !CKV Awcr ffiA E Mail Address "I Z EtI6,D f r(P YA if 00, cn M'
Drivers Lic.# R1CK Ni,5;J PN DOB 10 10,4 Drivers Lic.# Z11'�li,TMl,y15T7 DOB 14Z4-7107-59
SEPTIC INFORMATION - Connect to New Septic_ Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION- 12 Digit Parcel No 1 I � v 0 0 Fire District
Legal Description ^ t ci^i 365 31
Site Address (Please include street name, street number and city) s ID r.
Directions to site ILL4 Id t A dO, LOYA6,r4. ( rt1C r._,
Is property within200' of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff_yStream Slopes or Bluffs > 15%
TYPE OF JOB - New_,/ Add _Alt Repair Other_ Use of Building "
Location of Fixtures/Units - 1st Floor �! 2nd Floor ;✓ Basement V Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric_LPG✓Natural Gas— Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs t Heatpumps 0
Showers I Spot Vent Fan
Water Heater I Propane Tank
Clothes Washer ! Gas Outlets
Kithen Sinks ! Wood/Gas/PelletStove 0
Dishwasher ! Kitchen Exhaust Hood I
Hosebibs Dryer Vent I
Other Other (HkV) I
Base Fee Base 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 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 party 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 UATIO F WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Date: V /!
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by:___ Planning Pd_ Ck# Date __Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group—Type Constr.
Planning Department ,(
Environmental Health Department
FEES
Plumbing& Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/ Pellet Stove Fee Other
Violation Fee TOTAL FEES