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Home My WebLink AboutBLD2021-00611 SFR - BLD Application - 4/27/2021 MASON COUNTY COMMUNITY SERVICES Permit No:BId�Y I-(NA(6 I PERMIT ASSISTANCE CENTER: Sv •BUILDING.PLANNING•PUBLIC HEALTH•FIRE M C E 1 615 W.Alder Street,Shelton,WA 98584 Phone Shellon:(360)427-9670 ext.352•Fax:(360)427-7798 � 1 20 `. Belfair,(360)275-4467•Phone Elma:(360)482-5269 • BUILDING PERMIT AIRKMIA11614I ` PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: Tracey McGlothlin NAME: Adair Homes MAILING ADDRESS:P.O.Box 1867 MAILING ADDRESS:1311 SE Cardinal Court Ste 100 CITY: Shelton STATE:WA ZIP:98584 CITY:Vancouver STATE:WA ZIP-98683 PHONE#1:360-490-0100 PHONE:360-359-4520 CELL: PHONE#2: EMAIL: arobinson@adairhomes.com ` EMAIL: tdmac@windermere.com L&I REG#ADAIRH*262RZ EXP.01 /09 /23 PRIMARY CONTACT: OWNER4' CONTRACTOR❑ OTHER❑ NAME Tracey McGlothlin EMAIL tdmac((Dwindernere.com MAILING ADDRESS P.O. Box 1867 CITY Shelton STATE WA ZIP98584 PHONE 360-490-0100 CELL PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) 32021-53-02037 ZONING Residential LEGAL DESCRIPTION(Abbreviated) Township 20N Range 3W Sec 21 FIRE DISTRICT#5 SITE ADDRESS201 E.Midway Ln CITY Shelton DIRECTIONS TO SITE ADDRESS From WA-3N,exit Shefton/Bremerton,R.onto E.Railraod Ave,Left at 1st onto N Front St, becomes WA-3N/E Pine St,R onto E.Agate Rd,Rgnto Crestview Dr,slight left onto E Shorecrest Dr,Sharp right onto E Midway Ln. IS THE PROJECT WITHIN 300 FT OF SIiOPE(S)GREATER THAN 14'k: YES❑ NO,V SNOW LOAD:25 osf IS PROPERTY WITI"200 FT OF THE OWING: (Check all that apply): SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑ TYPE OF WORK: NEWpf AfTION❑ ALTERATION❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence.Garage,Co- Bldg,Etc.)Primary Residence IS USE: PRIVARYIVSEASONAIV NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS 2 HEATED STRUCTURE? YES(Whole1 YES(Part[V of Bldg)❑ NO❑ DACRIBE WORK New Construction Primary Residence,Single Family Home SQUARE FOOTAGE:(proposed) cap I ST FLOOR 1907 sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft. DECK `sq.ft. COVERED D CK sq.ft. STORAGE sq.ft. OTHER sq.ft. G�R j AGE 474 sq.ft. AttacheZetached[] CARPORT sq.ft. Attached❑ Detached❑ M MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* MAKE MODEL YEAR LENGTH WIDTH BEDROOMS BATHS SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGEISEWER SOURCE: S%41 SEWER❑ / NEW,@( EXISTING PLUMBING IN STRUCTURE? YES NO❑ , Ifyes,attach completed Water Adequacy Form PERIMETERTOUNDATION DRAINS PROPOSED? YES NO❑ EXISTING SQ.FT. 0 EXISTING BEDROOMS PROPOSED BEDROOMS 3 TOTAL BEDROOMS 3 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 interest regarding this project. The owner or legal representative,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 8 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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS_QF MORE WILL CAUSE THE APPLICATION T BE EXPIRED.(MASON UNTY CODE 14.08.42) X Sign ure OWNER(Must be signed by the OWNER) bate DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE I TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH MASON COUNTY COMMUNITY SERVICES Permit No:T�l—_d� l'do PERMIT ASSISTANCE CENTER: •BUILDING•PLANNING•PUBLIC HEALTH•FIRE M - 615 W.Alder Street,Shelton,WA 98584 Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798Q� 2 7 2021 Belfair.(360)275.4467•Phone Elma:(360)482-5269 P BUILDING PERMIT A61t1t4r PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: Tracey McGlothlin NAME: Adair Homes MAILING ADDRESS:P.O.Box 1867 MAILING ADDRESS:1311 SE Cardinal Court Ste 100 CITY:Shelton STATE:WA ZIP:98584 CITY: Vancouver STATE:WA ZIP98683 PHONE#1:360-490-0100 PHONE:360-359-4520 CELL: PHONE#2: EMAIL: arobinson@adairhomes.com EMAIL: tdmac@windermere.com L&I REG#ADAIRH*262RZ EXP.01 /09/23 PRIMARY CONTACT: OWNER.V CONTRACTOR❑ OTHER❑ NAME Tracey McGlothlin EMAIL tdmac windermere.com MAILINGADDRESS P.O.Box 1867 CITY Shelton STATE WA ZIP98584 PHONE 360-490-0100 CELL PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) 32021-53-02037 ZONING Residential LEGAL DESCRIPTION(Abbreviated) Township 20N Range 3W Sec 21 FIRE DISTRICT#5 SITE ADDRESS201 E.Midway Ln CITY Shelton DIRECTIONS TO SITE ADDRESS From WA-3N,exit Shelton/Bremerton,R.onto E.Railraod Ave,Left at 1st onto N Front St, becomes WA-3N/E Pine St,R onto E.Agate Rd,R onto Crestview Dr,slight left onto E Shorecrest Dr,Sharp right onto E Midway Ln. IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO,�r SNOW LOAD:25 Psf IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Checkau that apply): SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM[[] TYPE OF WORK: NIEWPP ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Resid m.Garage,Commercial Bldg,Etc.)Primary Residence IS USE: PRIMARY4/SEASONAL❑ NUMBER OF BEDROOMS 3 NUMBER OF BATHROOMS 2 HEATED STRUCTURE? YES(wholeB/dgAi(YES(Panrsl of Bldg)❑ NO❑ DESCRIBE WORK New Construction Primary Residence,Single Family Home SQUARE FOOTAGE:(pmpared) 1 ST FLOOR 1907 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 474 sq.ft. Attach Detached❑ CARPORT sq.ft. Attached❑ Detached❑ MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* MAKE MODEL YEAR LENGTH WIDTH BEDROOMS BATHS SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEC EXISTING❑ PLUMBING IN STRUCTURE? YES;; NO❑ If yes,attach completed Water Adequacy Form PERIMETER/FOUNDATION DRAINS PROPOSED? YE*/ NO❑ EXISTING SQ.FT. 0 EXISTING BEDROOMS PROPOSED BEDROOMS 3 TOTAL BEDROOMS 3 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 interest regarding this project. The owner or legal representative,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 ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS MORE WILL CAUSE THE APPLICATION T BE EXPIRED.(MASON UNTY CODE 14.08.42) X c?, 41 Sign re OWNER(Must be signed by the OWNER) Date DEPARTMENTAL REVIEW APP OVED DATE DENIED DATE I TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH MASON COUNTY COMMUNITY SERVICES Permit NotaJCxal yXypl PERMIT ASSISTANCE CENTER: 71VI •BUILDING •PLANNING •FIRE MARSHAL '° 615 W. Alder St-Shelton, WA 98584 qp� 2 7 �021 6� www.co.mason.wa.us �y DO Phone Shelton:(360)427-9670 ext. 352• Fax (360).427-j798 Phone Belfair.(360)275-4467• Phone E/ma:(360)4k-5269 PLUMBING & MECHANICAL PERMIT APPLICATION OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: Tracey McGlothlin NAME:Adair Homes MAILING ADDRESS: P.O. Box 1867 MAILING ADDRESS: 1311 SE Cardinal Court Ste 100 CITY:Shelton STATE:WA ZIP:98584 CITY:Vancouver STATE-WA ZIP98683 I"PHONE: 360-490-0100 PHONES60-359-4520 CELL: 2°d PHONE: EMAIL :arobinson@adairhomes.com EMAIL:tdmac@windermere.com L&I REG#ADAIRH`262RZ EXP.01 /09 /23 PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number): 32021-53-02037 Zoning: Residential LEGAL DESCRIPTION(Abbreviated): Township 20N Range 3W Sec 21 SITE ADDRESS:201 E. Midway Ln CITY:Shelton DIRECTIONS TO SITE ADDRESS:From WA-3N, exit Shelton/Bremerton, R.onto E. Railraod Ave, Left at 1st onto N Front St becomes WA-3N/E Pine St, R onto E.Agate Rd, R onto Crestview Dr,slight left onto E Shorecrest Dr, Sharp right onto E Midway Ln. TYPE 0JJ JOB: NEW ADD ALT REPAIR THER USE OF BUILDING LOCATION OF FIXTURES/UNITS—I ST FLOOR ND FLOOR BASEMENT GARAGE OTHER PLUMBING FIXTURES(SHOW NUMBER OF EACH) MECHANICAL UIYTS Type of Fixture No.of Fixtures Fees Fuel Type:ElectriW LPG Natural Gas Ductless_ Toilets 2 Type of Unit No.of Un' Fees Bathroom Sink 33 Furnace 11 Bath Tubs 2 ✓� Heat Pump 1 ✓ / Showers 2 Spot Vent Fan Water Heater �� Propane Tank Clothes Washer 1 ✓ Gas Outlets a Kitchen Sinks Wood/Gas/Pellet Stove Dishwasher 12, Kitchen Exhaust Hood 1 Hose bibs 2 Dryer Vent Other Solar Panel Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OWNER acknowledge 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 OFTHIS PERMIT IS BY MEANS OF INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. X el9la".1 Signatu er of Owner Date DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL Rev: 1/27/2016 JBN DocuSign Envelope ID:4B5F729F-9029-43D9-88FB-AA4F80B4771E Dow Sign Envelope ID:CBCEEM-11B67-4603-M17- 13432774G4M PLOT PLAN APR d 22; The tnformatiott on this Plan has been - r f•- tit; provided and reviewed by the _--vv r:; r;i Accepts full responsibility for its occur 11ro1�Te! 'er wfto(ry sujte[n9 lbw:1)Acknowledges a �-( BOO��J1 C6T�f is a with this tan 3 4Vitl�and cempleteness;2)Itnrts.lrespons ot lines ate nsure that the improvements to the site take place P 1 establish aU the corner'{ any ckange(s)to this plan must be pre-approved the �'Nuired setbacks required of this prof . and documented by 9overnmentat agencies urithjurisdiction,the mortgage lender,the contractor oomey y yr S� ��< .w��. Sig tr A,.iy-tl!_ Date 12/11/20 NING ecwa�ts3cFexaa� Date 2111120 2 0 __7 go' rk N I N G. ALL SETBACKS ARE MEASURED ` FROM T 1E FURTHEST �5CAIX;,72-0 PROJECTION 01=THE EUILUiN;; Cr rl�• �iropaced Cr °..' HOUSE t9' 190-1 0 , 9'r�►t N M to� IV P��eflt 15' soy Ito) � .� �'istcVA n J Zp2.t_ i. . E MIDWAY LN AQ�1icu-n,{-: �rau� ►�c.Glo-tl�ti►,� 21—S—q— o'Lo 3-7 P.qa t d ) WAADAIR}i'6R2o2o2a Adair Hodes Inc-Rev,,,.o 5ej+n,Uv"A-, � ,�sey APPROVED 1► <`N CrJUHTY OCD PLA.NN!NQ RITE PLAN REQUIRED TO DE ON SITE CHA r:S SUSJET TO APPROVAL fly iq—Dato �—�� Mason County WA GIS Web Map E E OE L 26 AMID LN 1 SH REC DR y1P NE 50 MIDWAY • 20 E BRI GERL`N 100E PANORA DR &Et HORRRE L • a 1 1 E PAN E P 0 ELINI= I WE T E � y 1 0 E RIDGER LN 120 MA DR• J � � r.. lI 1 EPA ESHORECR STDR c� t ' w u 1 1 E PAN c "' 13 E RA DRv o • E M AX �N E PANORAMA D 11,E MIDWAI(sLN 2 1 E ID Y LN • 9 MI DWA ; E RI ER N 1 OE S OREC ESTDR �O 291 E MIDWAY L ;o 1 1 EMI I!N 1 EMI AYL i• 1 0,E SHOR •CRESTDR 10 PAN 171E MIDWAY LN 3T TWA LN 71 HORELIN LN SHORECKE TDR E HOREC EST 61:SHORELINE LN 49X SHOD L NE LN E M DWAY $t` HO CR ST 41 E SHOREL�N 31 ESHORELII�E'LN • MIS YL jai),r 2 EIS ORECR-STD 'U 81'E'MIDWAY LN r0 24'E SHOlRELN LN 4/8/2021, 3:03:07 PM 1:1,536 0 0.01 0.03 0.05 mi 13 County Boundary 0 0.02 0.04 0.08 km Site Address (Zoom in to 1:5,000) Tax Parcels (Zoom in to 1:30,000) Sources:Esri,HERE,Gannin,Intermap,increment P Corp.,GEBCO,USGS, FAO,NIPS,NRCAN,GeoBase.IGN,Kadaster NL,Ordnance Survey, Earl Contours 20 ft (White) Japan,MET],Esri China(Hong Kong),(c)OpenStreetMap contributors,and the GIS User Community Contours 5 ft Mason County WA GIS Web Map Application Esri Canada,Esri,HERE,Gannin,USGS,NGA,EPA,USDA,NIPS i Richard Diaz _ DomSlgn Envelope ID:4BSF729F-9029-43D9-88FB-AA4FB064771E Dow Sign Envelope ID:CSCEEE2A-lB67_4B03,gg3F-3D432774C488 ADAIT7 ENVIRONMENTAL PLOT PLAN HEALTH AFR 2 7 2021 L�►4Z -dUt�'a r��v a-�� The infurmatims on this Plan has been provided and r t �._ `�� Accepts full r�P�sibilitY for its actor reviewed p'°Piter�ho (, {n conformance with this plan 3 Wily and complete,aess;2}Is responses and nsure that provernents to s aruf a -g an ) establish aU the corner trmts,lot site take p y change(s)to this plan must be pre-approved by the govtrntnerttat envies Cade required setbacks required of this propert ace y and dented ag >+ t 1fr*igdicti°r' the mortgage lender,the contractor a«miw.a q- Signa R?r'►<C �GSt{y,��,, Sig t !E'2'1'/'o 201* _43F-- EE] /2020 Sa' zo' D F D r- VT -to Scale Cr I � in 1s! �r-�pased v' HOUSE f 907 gr t3' rV8 D' 1O' AW 2.07- E MIDWAY LN flQplicG-n,{-: �r�cc� ►��Glot�,tiv.. �Jc of Pk""-e e.( 3 z o 21-s�- r7'Lo 3-7 P.",a WAADAIRH76R202020Ada1rFmeylnc.b -R.07/p AppROVED hIM 12 2021 MASONCOUNnE LYC IRONME%TALtiEALTH East Shoreline Lane ---------------------------------------------------------------------------------------- 80'-0" �4'- J. ..�.yvw.�WY1Yi+u/•/,,.w{wwwtu. -. (Proposed 3 Bedroom Septic "b w c O O O 10 0 5' 0" q (Proposed 3 Bedroom Residence) Bo M 13'-OIry (XXX East Midway Lane) 22--0" i o 62'-0" _I N � � O 80'-0" ----------------------------------- Lane SITE PLAN ��US T� CM IFS S eJET IC p:..: 4 a,:,, McGlothlin Residence - Plot Plan Namcrra(e, ry\cG Parcel# 32b21 -S 3 -OZ-0 3-7 f � Mason County REC I Department of Community Development APR 2 , 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 Calculate Impervious Surfaces Please Complete This Table Surface Type Length X Width = Area *All dimensions in feet Buildings X = 1907 X = Measurements for buildings are taken at the X _ perimeter of the farthest projections(example: eaves/gutters) X = Driveways 10 X 15 = 150 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 X = If the total impervious area of the proposed site X = development is greater than 2000 square feet a Small Parcel Stormwater Site Plan is Required Total Impervious Surface Area (sum of all areas) 2057 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 in pection as may be required. X Owner/Agent/Contractor(circle one)Date: Z. 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 � w Name Parcel# 32A2► -53-62037 BLD# 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: httn//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. A design by a registered professional may be required for more complex sites. *These details are found in the document Managing 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 A) The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed in 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.450 100 W PUBLIC WORKS DR 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. 352 615 W ALDER 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 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. X7 Owner/Agent/Contractor(circle one)Date: Page 2 of 2