HomeMy WebLinkAboutBLD2008-00165 SFR with Deck - BLD Permit / Conditions - 4/1/2008 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
Ir Shelton, WA 98584
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RESIDENTIAL BUILDING PERMIT BLD2008-00165
OWNER: DEBORAH REIS RECEIVED: 2/13/2008
CONTRACTOR: R K S CONSTRUCTION NW 490-7034-898-6683 LICENSE: RKSCOCN93ONP EXP: 8/17/21 ISSUED: 4/1/2008
SITE ADDRESS: 20 E 4TH ST (HOUSE) UNION EXPIRES: 10/1/2008
PARCEL NUMBER: 322325049017
LEGAL DESCRIPTION: UNION HOOD CANAL LAND & IMP CO BLK: 49 LOT 17-20 S OF RD
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
SFR WITH COVERED DECK CORNER OF MCREAVY BETWEEN 3RD AND 4TH IN UNION. MARKED
WITH SURVEY FLAS AND DEMARIO SYSTEM SIGN
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: 2 Occ. Group: R3 Lot Size: Deck:
Type of Work: NEW Fire Dist.: 6 No. of Stories: 2 Occ. Load: Building:1,408
Valuation: Building Height: Occ. Status: Primary Basement: cov deck 592
Manufactured Home Information Setback Information Shoreline&Planning Information
Make: Length: Ft. Front: E 40.0 Ft. Shoreline: Ft. Water Body: NONE
Rear: S 10.0 Ft. Slope: Ft. SEPA?: No
Model: Width: Ft. Side 1: W 5.0 Ft. Shoreline Desig.: Not Applicable
Year: Serial No.: Side 2: N 45.0 Ft. Comp. Plan Desig.: Rural Activity Ctr.
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Dishwasher 1 Exhaust Hood 1 Plan Check Fee KS 2/13/2008 $718.74 S12008000
Hosebibs 2 Ventilation Fan 2 Planning Review Fee KS 2/13/2008 $190.0o S12008000
Kitchen Sink 1 Woodstove 1 Water Adequacy Plan Review TW 2/25/2008 $40.00 S22008000
Lavatories 1 Dryer Vent 1 EH Plan Review GMM 2/27/2008 $100.00 9 bbo 000
Water Closets (Toilets) 1 Geotechnical Asses. Report BKD 3/12/2008 $320.00 S22008000
Water Heaters 2 Building State Fee MAL 3/14/2008 $4.50 S22008000
Bath Tubs 1 Building Permit Fee MAL 3/14/2008 $1,105.75 S22008000
Clothes Washer 1 Mechanical Base Fee MAL 3/14/2008 $26.60 S22008000
Mechanical Fee MAL 3/14/2008 $105.55 S22008000
Plumbing Base Fee MAL 3/14/2008 $23.10 S22008000
Plumbing Fee MAL 3/14/2008 $71.41 S2P008000
EH Permit Revision TW 3/27/2008 $40.00 S22008000
Additional Plan Check Fee MAL 3/28/2008 $32.00 S22008000
Total $2,777.65
BLD2008-00165 Please referto the following pages for conditions of this permit. 1 of 6
CASE NOTES FOR
BLD2008-00165
CONDITIONS FOR
BLD2008-00165
1) Prior to final approval, all upland areas disturbed or newly crip ated by construction activities shall be seeded, vegetated or given an equivalent type of
erosion protection (silt fencing or straw matting). X4(v-
2) 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 roadcopnect 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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3) The approval of this project is subject to the recommendations and specifications outlined in the attached geotechnical report or assessment. Structures
and/or land modifications (grading, cuts, fills, etc.) required in the geotechnical rep z
assessment, may require a seperate permit. The geotechincal
report/assessment shall remain attached to the approved building plans. X
4) 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 located 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 project.
5) Water quality is not to a degraded to the detriment of the aquatic environment as a result of this project.
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6) 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
X 800-647-098�j� 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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7) Approved pe di ensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
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8) Temporary erosion control measures must be implemented to prevent water qual2�x
e��adation of adjacent waters or wetlands. Silt fencing must be
installed and maintained until upland vegetation has become established. X
BLD2008-00165 Please referto the following pages for conditions of this permit. 2 of 6
9) 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 grant d. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and must be collected by the Building
Departmen io to any further inspections being performed or approvals granted.
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10) Owner//�?g nt is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
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11) 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
removal approved documents will result in failure of required building inspections.
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12) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X 444
13) 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
Building De rtment prior to any further inspections being performed or approvals granted.
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14) 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
underside roof sheathing is less than 12-inches and there is 1-inch vented airspace above the insulation.
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15) 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
BASIC WIN Z
EED (3-SECOND GUST)the wind speed for Mason County is 85 MPH.
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16) Per 2003 IRC-SECTION R905- REQUIREMENTS FOR ROOF COVERINGS- R905.1 Roof covering application. Roof coverings shall be applied in
accordance the applicable provisions of this section and the manufacturer's installation instructions.
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BLD2008-00165 Please referto the following pages for conditions of this permit. 3 of 6
17) A Mason County Stormwater Management Worksheet was completed and signed as part of this building permit application. Design, sizing, placement,
inspection and maintenance of stormwater management systems shall be the responsibility of the owner/agent of the developed parcel. It is the
owner/agent/contractor's responsibility to ensure that Mason County Department of Public Works has approved the stormwater site plan for this parcel
prior to the commencement of any development activities. "NOTE if Stormwater Management option "A" was selected on the Small Parcel Stormwater
Management Application/Worksheet the document entitled "Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan" constitutes
an approved plan based on the criteria listed on the application/worksheet. If the development has, or will have, a septic/drainfield system you are
responsible for contacting Mason County Division of Environmental Health to ensure that the stormwater system will not adverse) affect the septic stem
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of this, or any other, parcel. You may also wish to consult with the septic design professional involved with the project. By calling for a final inspection of
the building permit the owner/agent/contractor is a 10 ledging that all components of the stormwater management system have been installed as
approved on the stormwater site plan. X
18) 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
charged and' h lI be collected by the Building Department prior to any further inspections being performed or approvals granted.
19) 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
permit re rocation.
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20) 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, ga kets, mastics (adhesives), mastic-plus-embedded-fabric systems or tapes installed in accordance with manufacturers installation
instructions. Duct to e i OT permitted as a sealant on any ducts. Ducts in unheated spaces shall be insulated to R-8.
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21) 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 located 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 project.
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22) PlacementCf, stru ture must comply with standards set forth per the international codes regarding descending and/or ascending slopes.
BLD2008-00165 Please refer to the following pages for conditions of this permit. 4 of 6
23) All changes to "approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance oNgI elation, must be reviewed and approved by Mason County prior to construction.
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24) 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
X spector shall tf� de prior to requesting additional inspections.
25) All property lines shall be clearly identified at the time of foundation inspection. X_/
26) 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
Mason County gl�dinances and building regulations.
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27) 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
(older have prev n � action from being taken. No more than one extension may be granted.
28) The approval of this project is subject to the recommendations and specifications outlined in the attached geotechnical report or assessment. Structures
and /or land modifications (grading, cuts, fills, etc.) required in the geotechnical rep / ssessment, may require a seperate permit. The geotechincal
report/assessment shall remain attached to the approved building plans. X
29) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
connectors, flashing. Install metal connectors approved for contact with the new types of pressure treated material.
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30) Retaining walls needed to support a surcharges such as structures, roads, or to support slopes, shall require a separate building permit and approval prior
to construction of the retaining wall. X , �
31) Landings and stairs must meet the same setback conditions as any permitted structure; and, must be shown on your site plan. Please check your
"Approved a Ian"to ensure these structures are shown and meet the setback conditions listed.
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32) In buildings of unusually tight construction, fuel-burning appliances (excluding cooking appliances and domestic clothes dryers) shall obtain combustion
air from outside in a ith the international codes.
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BLD2008-00165 Please referto the following pages for conditions of this permit. 5 of 6
This permit becomes null and void if work orconstruction authorized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at any time after work is
dommenced. 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 ins pe�tion.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 property andruicture for re ' d inspection.
OWNER OR AGENT: DATE:
BLD2008-00165 Please referto the following pages for conditions of this permit. 6 of 6
MASON COUNTY PERMIT NO. F�Ly1-Oa JUI
F Lb IJILDING PERMIT APPLICATION
4 �edar• P.O. Box 186, Shelton, WA 98584 i
A$�t@�tov(�� 127 9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICA T LUEORMATION CONTRACTOR INFORMATION
Owner A. Company Name ' ;
Mailin Address e Mailing Address j n
City State Zip Code ` City / State I-0& Zip Code
Phone c Other Ph. Phone ACC G/ C, `;?,e 3--1 'Other Ph.AG
Lien/Title Holder Contractor Reg. # �!� 'O Exp.
E mail address ti Yej'jv-,t�Sc4-,�A00 E Mail Address ' - 6 0,v
Drivers Lic.# D B Drivers Lic. # brit�� �5�3/t)� DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic 4' Existing Septic
Connect to Water System y Name of Water System
Well Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No Fire District
Legal Description N
Site Address (Please include street na e, street nu ger and city) J <
Dire cti�s to site &/v kd, _ ,2� U%c'1e- "
Will timber be cut and sold in parcel preparation? Yes/(Ro
Is property within 200' of Saltwater C) Lake /V C) River/Creek P0 Pond A)y
Wetland N 0 Seasonal Runoff y Stream ..A2L) Slopes or Bluffs ] 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye N
TYPE OF JOB - New Add Alt Repair Other PRIM RY RESIDENCE 10 SEASONAL,❑
Use of Building lfgrq�,Z cc. Describe Work_ F�� a e u' ao"Ae�
No. of Bedrooms ���o. of Bathrooms�Square Footage- 1 st Floor l�7 2nd Floo( '�Gl
Flo 9r dement Deck Covered Deck Other Sq. ft.
2 aU rWe ` Attached Detached Carport Attached Detached
MA UFACT D HOME INFORMATION -Make Model Year
Leng Wid Serial No. No. edroo of Bathroo s
Type o at Purc e Price $ eplacement Unt , es/No
Installer Name 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 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 a rate and grants employees of Mason County access to the above described property and structure for review and inspection.
XROOF OF O TINUATIP ry ORK IS MEANS OF A PROGRESS DateECTIO) � cgo
Ow /Owners Re esentative/Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPRO D DENIED NOTES
Building Department ?/
Planning Department 1 �( �.- ( -
ICU I
Environmental Health Department "ia,
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee I
glrL EH Review Fee
Plumbing & Base Fee �� PlanningReview Fee
Mecha ical & Base fee CO SS Other
66jfGas/Pellet Stove Fee State Fee
Violation Fee I Pre-Paid at Submittal 7 L S'd
Valuation $ W TOTAL FEES
7777,
MASON COUNTY PERMIT NO.Z1)C�5_-
-�„ 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 INF RMATIO14
Owner Company Name
Mailing Addres Mailing Address
City &A State _Zip Code.'9 ice — City 1LN 1 0 State Zip Code
Phone Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. x .
E mail address 4,.,vT• rd a Q 4,L icwg C• E Mail Address
Drivers Lic.# &d DOBIJ 3j I Drivers Lic.fiA& DOB
SEPTIC INFORMATION - Connect to New Septic �� Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description
Site Address (Please include street n e, street number and
Direct'ons to site d a D
Is property within 200'of Saltwater AJa Lake River/Creek Po"d
Wetland Seasonal Runoff- "" Stream ---Slopes or Bluffs > 15%
TYPE OF JOB - New Add Alt Repair Other Use of Building
Location of Fixtures/Units - 1 st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANIPAL
Type of Fixture No. of Fixtures Fees Fuel Type: lectri LPCi_ Natural Gas_ Heat Pump_
Toilets Type of Un No. of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater . Propane Tank
Clothes Washer f has-GytIets
Kithen Sinks (�d/Gas/PelletStove
Dishwasher 1 Kitchen Exhaust Hood
1 Dryer Vent
Hosebibs
Other Other
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 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 oU4aaor County access to the above described property and structure for review and inspection.
PROOF OF CONTINUATION OF WDWtISBY MEANS OF A PROGRESS INSPECTION.
X Date:
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
Plumbina & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES
1916986 MASON CO WA
03/2512008 11:12 AM CERT
DEB RAH RE IS
#17713 Rac Fee: 42 00 Pa as 1
IIINII(IIIII III IIII IIIIIII 111111 IIII IIII IIIII IIIIIII I�I IIIII IIIII IIII�IIII IIII
Return to:
�+ L -4
U nlun . WA 61CD5c1a
CERTIFICATE OF RESIDENTIAL USE. LIMITATION ON NUMBER OF BEDROOMS
I(We)the undersigned,hereby place this notice on record that the following described real estate situated in
Mason County,State of Washington;to wit:(Division and Lot Number or Range/Township/Section Number.
Note: Range,townshipp,section numbers are the 1'5 digits of the parcel number)
un� n tkCA CA(IAl.
�,, '� Irvior. y�i 1I-a0 OR 113
Subdivision Division Lot Range Township Section
'
' Qedrz�om +[VsE'
and having the Tax Parcel Number of:a a,R3_2---5t�
-
is subject to the following understandings and conditions:
1. The use of this parcel will be restricted to no more than cR _bedrooms.
2. The on-site sewage system was designed for and the building permit was issu�cp on the basis of no more than
—bedrooms,and a maximum residential occupancy of no more than tj persons.
3. Use of the other rooms as bedrooms,in excess of the number identified herein,could result in hydraulic
overload and premature failure of the on-site sewage system,and could result in Mason County taking steps to
cause vacation of the premise.
4. In the event of any future residential remodeling,expansion,or replacement that results in additional
bedrooms to the number specified herein,the property owner will obtain the appropriate permits for expansion
of the on-site sewage system.WITNESS hand this day of I11,,.,1(k [7�
� ,20 Y
�r
NOTARY PUBLIC
sign tune State of Washington
Signature — KATHLEEN SOINE
Commlubn Espku A0009T 22,2010
State of Washington )
County of Mason )
I the undersigned,a Notary Public in and for the above named unty and State,do hereby certify that on this
_i By of �l(O,ie,r ,201�' �_6p,va JCi2ei S personally appeared before me,
who is known to be signer of the above instrument,and acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
No ary Public m and for t Se a of Washington,
residing at _
My commission expires
-�LYS� Request To Revise AnApproved Plan
3ermit Number: BLD2008 - Name v
Parcel Number 32Z � 0- U one Number daytime
Project Address 20 C y 5-- Mailing Address D. NoA z
Pleasi p ovids a complete, detailed desc 'ption of the proposed revisions to the approved plans:
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
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"desi@ned„plan will be approved without the written consent of the engiineerand/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes,Is a revised site plan,with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature Date: -
Office Use Only Received b
Date sent Assigned To Approved By Date
❑ B. Original Valuation: $
m J4L
((J L_ Additional Valuation: $
§rJ T50 Sq.Ft. x$ $
Sq.Ft x$ $
$ Total New Valuation $
P W Additional Fees:
Additional Planning Dept. $
Additional Plan Review $
Additional Conditions[Comments: Additional Building Permit $
Additional Plumbing $
Additional Mechanical $
Additional E.H.Dept. $ _
Other $
Total Amount Due: $
Amount To Be Paid Up-Front$