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Home My WebLink AboutBLD2011-00490 SFR - BLD Application - 6/17/2011 MASON COUNTY PERMIT NO. Bv'LDING BUILDING PERMIT APPLICATION 426 W. Cedar • P.O. Box 186, Shelton, WA 98584 �� 4 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 z. .6—_ Company Name _5/a/'� 'F A 5 Mailing Address Z/2 k y'f-,' Mailing Address City el 4-4 �(' State i,A Zip Code 3'2 Y City State Zip Code Phone_NCO-z 15 -CIF 0 Other Ph.a '75'-`i Phone Other Ph. Lien/Title Holder J,F r L rk j,E> -` C.4 L'c Contractor Reg. # Exp. E mail address d c i' �Z?_de1 s .c• ��y E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic ExistingS&pt+c ti�c. s v�- Connect to Water System Name of Water System Well Water System Name of Water System PARCEL INFORMATION-12 Digit Parcel No 2 47- - -,0 c� l 3 Fire District j Legal Description ✓`I L c 2 7 /'c 4 2, E A # C,i ;y 41-,; � t 07 �. Site Address(Please include street name,street number and city) X X Y aqV E_ .CZ A C_& �i�Z � S �• Directions to site Se-e A t42:- Will timber be cut and sold in parcel preparation?Yes o Is property within 200'of Saltwater .Al -9 Lake .QC, River/Creek ✓V 0 Pond ,.,U 6) Wetland NCB Seasonal Runoff ;� v Stream _Slopes or Bluffs > 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No /VO TYPE OF JOB -New Add Alt Repair Other PRIMARY RESIDENCE ® SEASONAL ❑ Use of Building tf't's% _ f��u Describe Work �- No. of Bedrooms No.of Bathrooms 2 Square Footage- 1 st Floor l< 3' . 2nd Floor i L'.2 3rd Floor AJ O Basement DecIe Covered Deck Other Sq.ft. <-- Garage Attached Detached Carport Attached Detached MANUFACTURED HOME INFORMATION - Make Mod Year Length Width Serial No. No. of Bedroo or No. of Bathroo s Type of Heat Purchase Price$ Replacem Unit? Yes/No Installer Name Certificaon No. OV11NE3/BUILDER Acknowledges submission of inaccurate information may result in a sto�Work order or permit re ment of such is by signature below.I declare that I am the owner,owners legal representative,or tft bonlractor.I further declare to receive this permit and to do the work as proposed in the application.I declare that I have obtained ft permission from all the If permission is required from any easement holder or any other party in interest regarding this application or the work proposed in lion,1 have obtained permission fromm._ft�m to apply for this permit and conduct the work proposed. The owner or agent on owners nts that the information provided is and grants of Mason County access to the above described property and stnxu ew and inspection. MPROOFNIU:A�01�ORK IS BY MEANS OF A PROGRESS WVECTION. ate Gers Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accept d by: t , ate - DEPARTMENTAL REVIEW APPROVED DEt6ED NOTEIS Building Department Planning Department Environmental Health Department ' IX -ffix Public Works Department Ilk hL Fire Marshal NJ EVO Buildinq Permit Fee NA IL IlSite Ins ection Aloe- Plan Review Fee EH Review Fee Plumbing& Base Fee IL Planning Re ' FMar Mechanical & Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Silomittal Valuation$ TOTAL FEES MASON COUNTY PERMIT NO. 1 � PANN�N'� BUILDING PERMIT APPLICATION C( L 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 ; Company Name A 5 Mailing Address XC ram.) Je y f(' Mailing Address City/1«�-A' State d Zip Code 9 f f-: `f City State Zip Code Phone=NCO-Z 75 -C210 Other Ph.s'w•- '73"-` 144, Phone Other Ph. Lien/Title Holder .7F r L= - Ile A-` CAX',c L` Contractor Reg. # Exp. E mail address E Mail Address Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic N,;5,?CZ Connect to Water System sk--Name of Water Systeml�- Well Water System Name of Water System PARCEL INFORMATION -12 Digit Parcel No 2 L el Fire District 5 Legal Description rqc c v ,3,L K ,? 7 ZCz- 22, i1- A tz G 1' y 4A- z Site Address (Please include street name, street number and city) 1'C A r,ram 4ir�� C S i. Directions to site Sc>e .4 2�62�-- 14 Will timber be cut and sold in parcel preparation? Yes o Is property within 200'of Saltwater eV �1 Lake ✓QC, River/Creek ✓V 0 Pond /-) cf) Wetland .AOc1 Seasonal Runoff v o Stream--/.-*'_Slopes or Bluffs > 15% Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No / O TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE Q SEASONAL ❑ Use of Building :+�'t'5: r-�,141,/ Describe Work No. of Bedrooms -�I- No. of Bathrooms Square Footage- 1 st Floor l.2' 2nd Floor i 3 3rd Floor Ar J Basement DecIe _Covered Deck Other Sq.ft. E- Garage Attached Detached Carport 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 Acknowiedges submission of inaccurate information may result in a stop work order or permit revocation.Ackri edgement of such is by signature below.1 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 f uTn_#v m to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information provided is and grants of Mason County access to the above descn"bed property and structure for review and inspection. PROOFp NUATiO ORK IS BY MEANS OF A PROGRESS INSPECTION. X Date? G Owner/ ners Representative/Contractor indicate which one FOR OFFICIAL USE BEYOND THIS POINT Accepted by_: T" 44 Date DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Planning Department -n Environmental Health Department Public Works Department Fire Marshal FEES Building Permit Fee Site Ins ection Plan Review Fee EH Review Fee Plumbing & Base Fee Planninq Review Fee Mechanical &Base fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee L Pre-Paid at Submittal Valuation $ TOTAL FEES t �1 A Drainage Culvert Drainage Culvert 20' �, F--- 25' Pi 1 r-T54' 1 52' PARKING 20' Pond Base 18, Stormwater Retention Pond 3 ft.Walk way 19'—� 66' � ( 1 Z Vacant Lot 22' �� • 1 . 1 I I 1 1 28' 1 10, Stormwater 120 I . 1 Run-off Path 1 Property& LV f� Property& 1 Fence Line r �` � 120' Fence Line j a 1 Proposed W 1 1 House ;- ' 0 1 North 3 � ; Stairs �W ,W: - liN 1 ---' • a >00 1 Property ' - 6. Ch 1 Line Only • � 1 14 Utilities 0 1 Rockery Easement 1 12-18" 1 E---- -- ,�----------------------� 10' APPROVED Blackwell St. MASON COUNTY DCD PLANNI^ SITE PLAN REQUIRED TO BE ON SITE Gravel Rd. CHANGES SUBJECT TO APPROVAL By PLANNING PLANNING: ALL SETBACKS ARE MEASURED FROM THr FURTHEST PROJECTION c;.r THE BUILDING 1 Drainage Culvert Drainage Culvert 20' E------- - 25' = ---------- 1 54' 1 52' PARKING 20' Pond Base 18' I 'I Stormwater Retention Pond 66' 1 3 ft.Walk way 19'—� 1 :3Z' I Vacant Lot r✓ 22(-�l I 1 1 28' ITT EELL �, Stormwater 120' I Run-off Path 1 1 1 I1 Property& Property& Fence Line Fence Line `I ZO 1 Proposed W 1 House ' �0_ i North ' ' Stairs E o c 1 la- W: ;W: -; O� LL � CO 00 Property - 6' P rch ' Line Only 1 T cc 14 Utilities 0 1 Rockery Easement 12-18" 1 E---- -- ,�----------------------� 10, APPROVED Blackwell St. MASON COUNTY DCD PLANNI Gravel Rd. SCHA ITE PLAN GES SURBJECTDTO APP�R,OOV�ALE By Date- I i PLANNIN PLANNING ALL SETBACKS ARE MEASURED FROM THE FURTHEST PROJECTION OF THE BUILDING Name U-4 ►�#�� Parcel# 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'. '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 = X = Measurements for buildings are taken at the perimeter of the farthest projections(example: X = t® eaves/gutters) X = Driveways X X = Length of drive begins at the right of way X = 30 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) o21 52— 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 pen-nit 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. 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. Page 1 of 2 BUILDING Name Parcel# 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: http//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 Mail:P 0 Box 1850, Shelton WA 98584 Physical:415 N 6th St, 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 Mail:P 0 Box 1666, Shelton WA 98584 Physical:426 W Cedar 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- roperty for review and inspection as may be required. f n X Owner/Agent/Contractor(circle one)Date: (�� /ar> Page 2 of 2 , :. tea € MASON COUNTY DEPARTMENT OF HEALTH SERVICES August 04, 2011 PO BOX 1666 Shelton WA 98584 Shelton (360) 427-9670 Fax (360) 427-8442 JEFF & DEBBIE CAREY Elma (360) 482-5269 PO BOX 480 ALLYN WA 98524 Belfair (360) 275-4467 Case No.: BLD2011-00490 Parcel No.-122205027003 Dear Applicant: Your building permit will not be approved by Mason County Public Health until the following items are completed and received in our office. Please see comments at the end of this letter. Please call me at (360)427-9670, ext. 279 if you have any questions. Sincerely, Amanda Reynolds Environmental Health Mason County Health Services Comments: Utilities will release the hold on your permit once the connection fees have been paid. 8/4/2011 Page 1 of 1 BLD2011-00490 Drainage Culvert .. �, Drainage Culvert 20' I � 20' Pond Base 18, 52' PARKING 1 IStormwater Retention Pond i 66' I F3 ft.Walk way 19'—� I 1 Vacant Lot 22' I I I 1 1 28' 10, Stormwater 120' Run-off Path I 1 2 ( 1 1 Property& I property& 1 Fence Line 120' Fence Line j a t Proposed W t o t House ' North ' Stairs 3 t 1 o? Eo = co ,w; w; — a C, 1 LLm '-- -- a > 1 Property e Only , 61 00 LPorch t Rockery 15' 14 Utilities ; 12-18" Easement t E---- -- lx4- ----------------------� 10, Blackwell St. Gravel Rd. V6,, C 42.t \ 222-2-O sa .z 7 a 7 � u�� , no wry jr2d ? MASON COUNTY PUBLIC HEALTH _ PO BOX 1666 SHELTON, WA 98584 LOCAL (360) 427-9670 Application for Determination of Adequacy BELFAIR (360) 275-4467 Instructions FAX (360) 427-7787. 1. Complete Part 1. No determination can be made until Part 1 is fully completed. 2. Complete only the portion of Part 2 applying to the type of water system utilized. 3. Submit completed application,with attachments to the health department for review. PART 1 : Applicant/Parcel Identification Name of Applican �fd3 i Gl V_1bA Date nze) Mailing Address �D �o1C �� o y h WA �g S a� Telephone 31oD S Assessor's Parcel Number 1as aD So a DD3 Type of Water System Check One): Reason for Application Check One): Public/Community Water System (2 or more Building permit connections)** ❑ Land use application, if so.. ❑ Individual water source (one connection), ❑ Division of land: if so.. ❑ Well #of Parcels? SPL - ❑ Spring/surface water ❑ Boundary line adjustment ❑ Other(explain) ❑ Other(explain) ** If you have more than one residence ❑ Replacement (please indicate name of water system connected to this well, check the Public box. below if applicable—no signature required) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water System C� Name of Water System �`4 � u m 171t� p+e r Water Facility Inventory (WFI) Number: (write "none" for two-party) I am the manager of this water system. The water system has been approved for9 services. There are presently:_connection(s) in u'se. This will be the 'a connection. ❑ I am the manager of this system. This connection will be to upgrade or change the use of an existing connection on this system i.e.: recreational to full time). Please indicate on the following line the nature of this change: This water system is able and willing to provide water to this (these) connection(s)without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System ManCger _Date ak 1 H.•I WELLTORMnWATER,4D4.DOCUpdate:October 2010 COMMUNITY [DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW Mason County Public Health Official use only r� 415 N. 6th Street Permit Number: � 't( -(2c)+v PO Box 1666 ll Shelton, WA 98584 Date Received: Shelton: (360) 427-9670, Ext. 400 - Belfair: (360) 275-4467 Ext. 400 Amount Received Elma: (360) 482-5269 Ext. 400 Receipt Number ��aG Fax (360) 427-7787 Applicant Information Type of Review Applicant J(2-Q, d- bi Cam Date )I Building Permit Mailing Address ny_ L/ �d New 0 Replacement 11 o 13 Commercial Building Permit City State Zip 13 New 13 Replacement ?,�o a�S-O�0 Soh aRS-�$a� 0 Building/Commercial Permit Revision Daytime Phone Other Phone 13 Tenant Review E-Mail Address Cl p Pre-Application Parcel Information 12-Digit Parcel Number I 12,ap - �5D -9000� Site Address Street Number Street Name City Type of Job Please submit a scaled plot plan Describe work fI ) u-) showing all existing and proposed building, on-site sewage system, Number of Bedrooms �-- and well. On-Site Sewage Information Water System Information 13 On-Site Septic System 0 New 0 Existing Plumbing in structure? '&�Yes 0 No (* Sewer Name of Sewer System If yes: Using an existing on-site septic system will require a current please submit a completed Water maintenance report and a Record Drawing (Asbuilt). Documents Adequacy Form. for both of these requirements may be on file with Mason County Public Health. Other requirements may apply. ant 'g Date Official use only Departmental Review Approved Denied Not.. Water Adequacy On-site Sewage System Tenant Review Revision Revised 12/17/09 Individual Water Well ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test (attach to application) gpm e well driller otten performs we capacity tests at the time the well is constructe esu is from these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test, a well capacity test, which provides stabilization of draw- down and recovery data, must be performed by a licensed contractor. U Satisfactory bacteriological test(attach to application) Individual S rin /Surface Water ❑ WDOE permit —Water right (attach to application) ❑ Method of disinfection (attach design to application) ❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or provides water at a rate of 2 gallons per minute based on the following observations. AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLCANT IN ADDITION TO PROVICJNG THE ABOVE STATEMENT,THE APPLICANT WILL NEED TO ARRANGE AN ON•SITE INSPECTION BY THE HEALTH DEPARTMENT PRICK TO DETERMINATION CF ADEQUACY. non"rtm, ntdl1:ISE'■.on;Iy __. nA. nnf xA/Cl,ipiac ■ PART 3: Health Department Evaluation (Staff Use Only) SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to l meet the needs of its intended use. This determination does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely into the future, orguarantee compliance with all applicable WDOE water resource regulations. ❑ UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason (s): REVIEWER'S SIGNATURE DATE 14 ll' H:• WELLIFORMSIWA TERAD4.DOC Update:October 2010 Drainage Culvert 20' Drainage Culvert F 25' E - - 1 54' 1 20' Pond Base 52' PARKING 18' I ( 1 Stormwater Retention Pond 1 1 all- ll- 3 ft.Walk way 19'—� � 66' A1 1 Vacant Lot i 22' 1 1 I I 1 1 28' 1 T 1 10, Stormwater 120' 1 I 1, I Run-off Path 1 12 1 I 1 Property & j Fence Line , �, Property 8, 120 Fence Line j a 1 Proposed W �- House 1 North Stairs " 1 LL ;w: � 1 :0 o IN' Uj: 1 - -- • a > 1 Property ' 6' Porch Ij Line Only D 1 • `� 1 Rockery 15' 14 utilities ; 12-18.. Easement 1 E---- -- 7----------------------� 10, Blackwell St. Gravel Rd. f Drainage Culvert Drainage Culvert 20' 1 54' 1 PARKING 20' 4 18 Pond Base , 1 ' 52' I Stormwater Retention Pond i P ft.Walk way 19,—� 66' 1 L, 1 IV„/ N Vacant Lot 22' 1 1 1 1 I 10' I Stormwater - 120' �, Run-off Path 1 1 Property 8, , Property& 1 Fence Line • 12b' Fence Line j Proposed W 1 1 • House ' 1 North ' I Stairs 3 1 • EW w? ia' _— Li N j _ • a > 1 Property ---. 6' Porch 20 ' Line Only 0 w 1 Rockery 15' 14 Utilities 12_18" Easement 1 E---- -- 7----------------------� 10, Blackwell St. Gravel Rd. BUILDING