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MASON COUNTY PERMIT NO.
BUILDING BUILDING PERMIT APPLICATION '_Rq) c c 7q
426 W. Cedar• P.O. Box 186, Shelton,WA 98584
Shelton(360) 427-9670•Belfair(360)275-4467•Elma (360)492-5269
On the web www.co.rnason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION l r
1 i� Company Name '
Ownet` Mali Address
Mailin Address State 14_1�1 - Zip Code
City 1 State Zlp Code City
h�/ ;_ Phon I � Other PhZ_�
Phones Z-� Other P �G'�'C� � ch? d'
Contractor Reg.# P
LierJ Title Holder v 5tc�, c r
E mail address - E Mail Address
Drivers Lic.# �-- _ DOB Drivers Lic.if$�+'��I�i.�I'� J �DOB (�-/5�'�
SEPTIC/WATER SYSTEM I ORMATION-Connect tg New epti Exis'ng Se tic
Connect to Water Sy Name of Water System C
Well Water System Name of Water System r
Fire District
PARCEL INFORMATION-12 pigit Parcel No—
Legal Description v i
Site Address(Please include street Iarse,streetm1 ur and c fir �Sat' i
Di ionstite _ 1J6/Q
Will timber be cut and sold in parcel preparation?Yes Pond
Is properly within 200' of Saltwater Lake River Creek
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?Y
esMV
TYPE OF JOB-New V Add Aft Repair Other PRIMARY RESIDENCE❑ SEASONAL
5 �-
Use of Building. �� - Describe
No.of Bedrooms
No.of Bathrooms 2 Square Footage-1 st Roor�--2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION ,Make Mode Tc'Yea
Length.��Width�Serial No._.2-1 1 No.of Bedrooms No Bathrooms
Type of Heat �L"� if- Purchase Price� �f��LfS� Replacement Unit? Yes No
Installer Name '�%`"'r` Certification No
OWNERI BUILDER Aclmowledges submission of haccurate information may result in a stop work order or permit revocation.Acimowledgerrent of
such is by signatze below.I declare that I am the owner,owners legal represent bie,or the contractor.I further declare that I am entitled to receive this
permit and b 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
paam fission from them to apply for this per it and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is aoutzaie and grants employees of Mason County access to the above described property and structure for review and inspection.
PR F OF NTWUATi OF WORK IS BY MEANS OF A PROGRESS INSPECT)O
X
Date
er/Owners Repres 1 bontracto (indicate which one)
FOR OFFICIAL USE B OND T S POINT Accepted b '' '1 Date 1 .
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department ;
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Build'inq 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
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Name Ifg�_ Parcel i42_6d d --- o --&62_e7 BLD#_2��— X i
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'.
'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=Calculafe lmpervlous Surfaces Please Com /ete This Table
P
Surface Type Length X Width = Area "All dimensions in feet
Buildings 69 X A & _ 2-0
X = Measurements for buildings are taken at the
perimeter of the farthest projections (example:
X = eaves/gutters)
X =
Drivewa s C X �/() = ZOO
X = Length of drive begins at the right of way
X =
Parking Areas C X 3 Q Any paved, gravel or packed area per definition
X = above table
X =
Patios/Walks X =
X = Any paved, gravel or packed area per definition
above table
X =
Others X =
X = If.the total impervious area of the proposed site
X = development is greater than 2000 square feet a
Small Parcel Storm water:Site Plan is Required
Total'Im pervious.Surface Area(sum of all areas)
If the Total Impervious Surface Area is LESS THAN 2000 Square Feet,please read,acknowledge and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NO required for this development activity.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may r ult in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owne legal representative,or the contractor.I
further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above-
described property for review and inspection as may be required.
X Owner/Agent/Contractor(circle one)Date:
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. �y
Page I of 2
+ ACCESS & GRADE INSPECTION BLD I ' OC�18
ADDRESS: I I f111v l ��
INSPECTOR: DATE OF IN PECTION: L
FIRE SPRINKLER REQUIRED? (circle) NO YES
IF fire sprinkler required, was notification letter mailed? D ATE MAILED:
DRIVEWAY ACCESS FIRE
( ) need post at access of driveway with reflective address numbers MARSHAL
Length: Width: Sur lace:
Size of turn-around:
Condition of shoulders:
Vertical clearance:
GRADE OF DRIVEWAY %, OF ROAD %
ROAD ACCESS
Length: Width: S ce:
Condition of Shoulders:
Vertical clearance:
BURN PERMIT REQUIRED FOR LAND CLEARING FIRE.
L� LOT INSIDE UGA—NO OUTDOOR BURNING PERMITTED.
LOT TOO SMALL FOR: BURN PERMI S 4 X 4 FIRES
2 X 3 FIRES
PASSED ( ) FAILED ( ) ON HOLD ( )
REMARKS:
2012
%4ASON COON N'