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Home My WebLink AboutBLD2024-00575 MFG Home - BLD Application - 5/8/2024 NAME V NAME: B VD L[—OO� y MAI NG ADDRESS:iw MAILING ADDRESS: CITY ✓1 STATE. ZIP: CITY: ST ATE: ZIP: PHONE#1: S. PHONE: CELL: PHONE#2: EMAI : EMAIL L&I REG# / CONTACT PERSON: OWNER CONTRACTOR iOTHE N Yi" ',L SGADDRESSAIIIftt"CITY STATE: ZIP: �� PHONEIS3.1,14."1111-IeELL: EMAI ,: J�kyen w Q r�ord� esr Street PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) 422045000087 ZONINGRR LEGAL DESCRIPTION(Abbreviated) Lake Cushman #5 TR 87 FIRE DISTRICTI 8 SITE ADDREss431 N MT JUPITER DR CITYHoodsport DIRECTIONS To SITE ADDRESS 101 North to 1 19th North, left to Dow Mountain Rd., riqht to Mount Juniper, riqht to property IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO 0 SNOW LOAD:5_psf IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply): SALTWATER ❑ LAKE ❑ RIVER/CREEK❑ POND ❑ WETLAND❑ SEASONAL RUNOFF ❑ STREAM❑ TYPE OF WORK: NEW ❑ ADDITION❑ ALTERATION ❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence, Garage,Commercial Bldg,Etc)residence IS USE: PRIMARY 0 SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS2 HEATED STRUCTURE? YES (Whole Bldg) 0 YES(Part[sl of Bldg) ❑ NO ❑ DESCRIBE woRKplace a new manufactured home on the lot - will use existinq utilities SQUARE FOOTAGE: (proposed) 1ST FLOOR1350 sq. fl. 2ND FLOOR sq. ft. 3RD FLOOR sq. ft. BASEMENT sq.ft. DECK_36 sq. ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft. GARAGE sq. ft. Attached❑ Detached❑ CARPORT sq. ft. Attached❑ Detached❑ MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED' MAKESWine MODELWBstridge 1299 YEAR2024 LENGTH50 WIDTH27 BEDROOMSI BATHS2 SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW ❑ EXISTING PLUMBING IN STRUCTURE? YES 0 NO ❑ If yes, attach completed Water Adequacy Form PERIMETER/FOUNDATION DRAINS PROPOSED? YES ❑ N00 EXISTING SQ.FT.0 EXISTING BEDROOMS PROPOSED BEDROOMS 1 TOTAL BEDROOMS 1 OWNER acknowledges that submission of inaccurate Information may result In a stop work order or permit revocation.Acknowledgement of such is I 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 11 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 OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42) X I r 4/6/2024 Signature of OWNER(Must be signed by the OWNER) Date DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH Mason County Building Division MANUFACTURED HOME PLAN REVIEW SPECIFICATIONS UNIT INFORMATION: *****Snow Load cJ�J Make Skyline Model Westridge Year2024 Square feet 1350 Width 27" Length_50 Single/Double/triple-wide(indicate)NEW or Replacement indicate) All footings must be min. 12" below natural grade within 24"of the skirting when perimeter blocking is required. When a relocated unit AND the manufactures specification are not available the HUD 24 CFR 3285 must be used for required pier plan,standards and set-up. Allowable Pressure(Pound Per Square Foot)No Allowances made for overburden pressure,embedment depth,water table hei ht,or settlement problems Soil bearing is assumed at 1500 psi If set-up Is using a greater soil bearing capacity a soil report from a design professional is required Fill compact or uncompacted) Compaction Report required through Special analysis Peat or organic clays Compaction Report required through Special analysis SET UP SPECIFICATIONS: ® Manufacturer's Pier Plan O HUD24 CFR part 3285 FOUNDATION: Check the type of foundation and attach detail plans from manufacturer's or the ANSI A225.1/HUD24 CFR part 3285 7- pods __ 0 Concrete(pre-cast) O ABS Pads(Poly)provide manufactures specification with capacities. O Continuous concrete footing(runners) ANCHORING: %5f Slab M Ground 71 Magnum 71 Concrete-2500 PSI O J-bolt 0 Expansion bolt For new units,this information can be obtained from the home retailer or contractor. Previously owned units,which manufacture's instruction are not available must utilize the HUD24 CFR part 3285 code for installation.Washington State law requires that a certified installer install manufactured homes. The undersigned I hereby acknowledge he/she does understand that the Mason County submittal and review processes will be based on the information provided herein and will be verified at time of inspection. X Date 5/1/24 $�.G ..,. '.der_::Y�� •ii��;T i'�:!' '�...�,5-, y t !,.ir'4:( .. :a - _ t'=t, ,t WOW)' ' ry [•t,.�- .t�.. ,. sj`, r-.. .. . ..;i. 3' ...td �:'„�.;r ¢.fl:' }�y t�i':� ;}�ii i� '��. .. ., x«F': . f• Dil yy r 5 et; i$ , 11 t•' s,'. �''.. t f 't•.f.. :.iti�� '.�.NT��-Y.! t. „ - i. T:�.Y'. .r. �l .'y: ° I �t t . _'n`. �F' ,-:^,�� Si '�. t��r {.7�'Y� a. ,�Fr: l�.}?ata ,A. ij,•_.fit^.. .. �.;` r_ :'�' , PART 1: PURCHASE AGREEMENT A: PARTIES: Buyer: Mark Ferderer Buyer: DETRAY'S CUSTOM HOUSING LLC Address: 936 Pike PL NE City: Auburn 10209 149th St.F. State: WA Zip: 98002 Puyallup,WA.98374 Email: markferderer@mail.com Phone: 253.315.3214 Prepared Sr. Jonathan 1st Date Prepared: 1/14/23 Revision#: 1 Date: 313112024 B:AGREEMENT T- PURCHASE: Buyer agrees to purchase from Seller under the terms and conditions specified in this document the following described manufactured home together with the furnishings,accessories and services indicated hereon.Property described as"new"is property on which no state certificate of title has been issued.See also Part n, para.2 and 5(b). Manufacturer: 5kyhl,�- Model: Approximate Size: Length: Width: 21 W/o Eaves 1 Model#: '2'` Factor Order Substantial) Same as Serial#: Year: �'G2 #Bedrooms: Y Y Home is: Newt ]Used Lot Model ❑Yes; �(]No Unit Sold Has Been Inspected by Buyer. [] Yes (�] No j -. .. C: RECORD OF TRANSACTION: CHARGES: 11. Payment-Itemization: 1. Agreed Price of Property: onion Earnest Money Deposit,Down Payment; 2. Adjustments: Consisting of the Following: NJ, ,A00 waF1Cc11; &SI)P(i=i,t,tior,�: a.Earnest Money Received: $ 1,000 List below any special choice of Buyer as to materials, _ accessories,or Furnishings. Items such as Furniture,Heat Pumps, ❑ Funds Wired ❑Credit Card ❑✓ Check ❑Cash Air Conditioner,the Tape and Texture repair kit,good after one year,or any closing cost requested by the lender.Items required Earnest Money maybe nonrefundable by the County such as the Type of Siding for Fire Rating or a Fire with recission;Part 1 Para H Suppression System,or a Singular Sprinkler in front of the Range. b.Down Payment to Order: $ 100,Ooo ❑ Funds Wired ❑Credit Card Q Check ❑Cash Gutters and Down Spouts, Decks, Awnings, Tie Downs, Skirting, Steps, any Decor, Furniture and other options in our Display c.Additional Payment Toward Balance: $ Homes that are not included in the sale unless specified herein ❑ Funds Wired ❑Credit Card ❑Check ❑Cash showing the additional cost of each Item below. $ 750 d.Final Balance Due Before Delivery: ❑ Funds Wired ❑Credit Card ❑Check ❑Cash $ (2,000) $ Subject to Part 11,Paragraph 4 and 13. Q Check Further specifications Attached: D:ENTIRE.AGRt t.MFNT; CONTRACT PARTS: This Agreement includes Parts 11 through V and all other written terms, conditions and understandings accepted by the parties as part of this 3. Total Adjustments(as shown above) transaction which are deemed to comprise a single contract document and constitute the entire agreement of the parties.Each paragraph and provision of this contract and all parts hereof is severable, If one portion thereof is 4. Delivery to Home Site&Installation $ ^_ invalid the remaining portion shall, nevertheless, remain in full force and subject to Part 11 para 7,and Part IV. effect. Delivery,Installation,&Site Requirements Agreement. E.PRIOR AGREEMENTS,MODIFICATIONS: This Agreement supersedes all prior negotiations, orders, offers, agreements 5.Contingency Allowance: Part I Par L 1.50% $ 2,747 and representations,either oral or written.This Agreement may be modified or � partly superseded by later written agreement of the parties attached hereto 6. Subtotal:Adjusted Sales Price: I :;..:.�'?7t and incorporated herein. 7. Sales Tax: 7 Check % $ 15,800 V F. DELIVERY: Estimated Delivery Date: 8. Excise Tax: []Check % $ Place of Delivery Address: 431 N Mt.Jupiter Drive City: Hoodsport County: Mason 9. Non Taxable Fees (Title and Processing) $ 750 Additional Item: �'$ - State: WA Zip Code: 98548 10.TOTAL ADJUSTED PURCHASE PRICE: ®� Park: Space: Acceptance x x ,� — DATE. 3/31/2024 by Seller: Dana or Diane DeTray Mark Ferderer 3131/2024 Company Title _OwnerlPartner x DATE. 31311202q MIPORTANT NOTICE TM65 NOTASURVEY rNE IhFORMARONANO LOCATIONS SHOWN HEREAV ARE DERNEO FRO4 FWALK R[CORDS.OWNER S ATEMENTS. AHOF4tDOaSERVATRWS. UT 5 MOWWARPANTYEXPRSMNS RIHPLIEO 10ACCURACY NERC-COAWIENp TlWIlFN DUE$TION$EXIST EH Setbacks THE OWNER r1eTAAV THE SERVICES OT AIMfNSED PROFESSgNAL UMJ SLFVEYON PRN)R IO CGNSIRIlLIION OR RELIANCE ON ileSWFORMATKK! MlS RA'CRAHMwlS ONLY W/ENDED FORTNE PVRPoSFS OF SEPTIC sYSIEN LONsmurmwANoes alwlLDanNR A.) Drainfield/Reserve requires 10'setback from footing/foundations EH APPROVED B.)Septic tank(s)requires 5'setback from all footing/foundations Rnonoa Thom 81 020Z�)'00 pson os 1e zoza �J CJ C.)No foundation/Perimeter Drains within 30ft,downgradient of \ Drainfield/Reserve area D.)No Cut Bank(s)(greater than 5ft and over 45 degrees)within SOft,down gradient of Drainfield/Reserve area \ SOIL LOGS: TAKEN 4/22124 SL1 6 SL2 \ 00-24'LOAMY TYPE 1 24-56'TYPE i sff0< � TANK NOTES: �90 \1: 1.EXISTING 1,000 GALLON CONCRETE TWO COMPARTMENT SEPTIC TANK. n \ G .rA✓A L 000 DecN y �j5 \\ EJt\ " RV/DUMP TING BEpRpEN E aMEO SILT FENCEPROPOSED RESERVE \ SAND LINED WASHRO KDPRESSURE BED 10'X 24' � "Of'. w "OPO¢PM x REST PROPOSED \� WITH ADDITIONAL 6'ASTM-33 SAND COLLAR. 5 1e,1 U0 SINGLE 50 P0.s pWA rER� 240 SQ FT ABSORPTION AREA,IN TYPE 1 SOIL. �5• \ 72LF OF 1.5'PVC LATERALS 3.33'O/C. a1` O _1' ORIFICE SPACING 21' O - (14 ORIFICES PER LATERAL) \ id � TOTAL DIMENSIONS ARE 11'r25' '1` CONIFER fTYP) \ (WATER LINE TO BE RELOCATED IF MW RESERVE DRAINFIELD IS INSTALLED) W EXISTING PRIMARY DRAINFIELD: - GRAVITY D/STRUBITION 42LF GRAVEL TRENCH PREVIOUSLY APPROVED TO SUPPORT YWO BEDROOM ,,,�,;,.A DWELLING. one SITE ADDRESS:431 N MT JUPITER DR R,p-t d:uv1u2024.IRep---Type ROUTINE- SEPTIC SYSTEM DESIGN PARCEL NUMBER:422045000087 t J DIP Wled ok eI this tNRe. g -AAA Septic LLC ALLEGIANT LEGAL DESCRIPTION: METESAND13OUNDS 22010790 DAViO HILEY SEPTIC DESIGN,LLC. CLIENT: MARK FEDERER N �E DAVID HILEY TELEPHONE:253.315.3214 253.77T.Ml ADDRESS:431 N MT JUPITER DR 20' 40' DAVID®ALLEGIANTSEKCDESIGNCOM HOODSPORT,WA98548 DATE:4/30/2024 PAGE 1 OF 1 oil 1 Name Parcel#A 2.2.Oti- 50- 000 5-1 BLD# B>_D202A- 005-15 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 50 X Z.-1 = l 3 5 0 X = Measurements for buildings are taken at the X — perimeter of the farthest projections(example: eaves/gutters) X = Driveways X = 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 = DECK X = 3tv 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) 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 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 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: httpHwww.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- described property for review and inspection as may be required. X Owner/Agent/Contractor(circle one)Date: Page 2 of 2 Name Mark Ferderl,111, Parcel# 422045000087 BLD# 20 ZA —OOS-7 C-:1 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. 2Common 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 50' X 27' = 1350SF X = Measurements for buildings are taken at the X _ perimeter of the farthest projections(example: eaves/gutters) X = Driveways 20 X 20 = 400SF 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 = Porch/Steps 4 X 9 = 36SF 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) 1786SF 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 inspection as may be required. X c4z� Owner/Agent/Contractor(circle one)Date:_5/l/24 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 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: hgp//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 Stone 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- described property for review and inspection as may be required. X Owner/Agent/Contractor(circle one)Date: Page 2 of 2