HomeMy WebLinkAboutBLD2011-00081 Final SFR - BLD Permit / Conditions - 11/9/2012 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
Shelton,WA 98584
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RESIDENTIAL BUILDING PERMIT BLD2011-00081
OWNER: JEFF WERDALL RECEIVED: 2/2/2011
CONTRACTOR: LICENSE: EXP: ISSUED: 4/6/2011
SITE ADDRESS: 2501 E STATE ROUTE 302 BELFAIR EXPIRES: 10/6/2011
PARCEL NUMBER: 122162100001
LEGAL DESCRIPTION: GOUT LOT 1' EASTERLY OF R/W S 33/235
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
RESIDENCE (WILL BE ADU-WHEN HOME IS BUILT) ST RT 3, TO ALLYN, R ON NORTH BAY ROAD, FOLLOW TO ST RT 302,
FOLLOW TO SITE ADDRESS ON THE LEFT SIDE
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: 1 Type of Constr.: VB
Type of Use: SF Insp.Area: No. of Bathrooms: 1 Occ. Group: R3U Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 2 Occ. Load: Building:1,378 Garage-Attached 1,000
Valuation: Building Height: Occ. Status: Primary Basement: cov deck 132
Manufactured Home Information Setback Information Shoreline&Planning Information
Make: Length: Ft. Front: W 430.0 Ft. Shoreline: Ft. Water Body:
SEPA?: No
Rear: E 200.0 Ft. Slope: Ft.
Model: Width: Ft. Shoreline Desig.:
Side 1: N 150.0 Ft.
Year: Serial No.: Side 2: S 170.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Dishwasher 1 Exhaust Hood 1 Plan Check Fee GMM 2/2/2011 $798.82 S12011000
Hosebibs 3 Ventilation Fan 1 Planning Review Fee GMM 2/2/2011 $205.00 S12011000
Kitchen Sink 1 Dryer Vent 1 EH Plan Review KKK 2/2/2011 $103.00 S62011000
Lavatories 2 Water Adequacy Plan Review KKK 2/2/2011 $103.00 S62011000
Water Closets (Toilets) 1 Building State Fee DLC 2/18/2011 $4.50 S12011boo
Water Heaters 1 Building Permit Fee DLC 2/18/2011 $1,447.35 S12011bob
Bath Tubs 1 Mechanical Permit Fee DLC 2/18/2011 $31.20 S12011bob
Clothes Washer 1 Mechanical Base Fee DLC 2/18/2011 $28.50 S12011bob
Plumbing Permit Fee DLC 2/18/2011 $75.80 S12011000
Plumbing Base Fee DLC 2/18/2011 $24.70 S12011000
ADJUST--Plan Check Fee DLC 2/18/2011 $141.96 S12011000
Total $2,963.83
BLD2011-00081 Please referto the following pages for conditions of this permit. 1 of 5
CASE NOTES FOR
r B LD2011-00081
CONDITIONS FOR
BLD2011-W081
1) 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
per r vocation.
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2) All changes to"approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordi or regulation, must be reviewed and approved by Mason County prior to construction.
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3) 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
char hall be collected by the Building Department prior to any further inspections being performed or approvals granted.
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4) 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
Ins a for shall be made prior to requesting additional inspections.
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5) 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
Mas ount ordinances and building regulations.
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6) A minimum of 50 percent of all luminaires shall be high efficacy luminaries unless lighting compliance was approved using the options available in WSEC
Section 1520 or 1530. Luminaires providing outdoor lighting and permanently mounted to a residential building or to other buildings on the same lot shall
be high efficacy luminaries unless permanently installed outdoor luminaires are controlled by a motion sensor(s) with integral photocontrol photosensor or
installed in or around swimming pools or water features. All fluorescent fixtures must be fitted with T-8 or smaller lamps (but not T-10 or T-12 lamps).
Ref�WSEC 505.
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BLD2011-00081 Please referto the following pages for conditions of this permit. 2 of 5
7) " 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 proje�
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8) A permanent certificate, completed by the builder or registered design professional, shall be posted within three feet of the electrical distribution panel.
The certificate shall list the predominant R-values of insulation installed in or on ceiling/roof, walls, foundation (slab, basement wall, crawlspace wall and/or
floor), and ducts outside the conditioned spaces; U-factors for fenestration; and the solar heat gain coefficient(SHGC) of fenestration. Where there is
more than one value for each component, the certificate shall list the value covering the largest area. The certificate shall list the type and efficiency of
heating, cooling, and service water heating equipment, duct leakage rates including test conditions as specified in WSEC Section 503.10.2, and air
leakage results if a blower door test was conducted.
Building envelope air leakage control shall be considered acceptable when tested to have an air leakage less than 0.00030 Specific Leakage Area (SLA)
when tested with a blower door at a press of 50 Pascals (0.2 inch w.g.). Testing shall occur at any time after rough in and after installation of penetrations
of the building envelope, including penetrations for utilities, plumbing, electrical, ventilation, and combustion appliances and sealing thereof. The blower
door test results shall be recorded on the permanent certificate required located near the electrical distribution panel. Air leakage testing is not required
for additions less than 750 square feet. Reference WSEC 105.4 Certificate and 502.4.5 Building Air Leakage Testing.
Compliance certificates are available online at the WSU Energy program website titled, "WSEC 2009 Certificate" and are available in '/4 or'/sheets. The
Mason County Permit Center will also have some available.
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9) 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
(ol � prevented action from being taken. No more than one extension may be granted.
10) 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
rem f ap roved documents will result in failure of required building inspections.
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11) 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 granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and must be collected by the Building
De nt prior to any further inspections being performed or approvals granted.
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12) All property lines shall be clearly identified at the time of foundation inspection. X
BLD2011-00081 Please referto the following pages for conditions of this permit. 3 of 5
13) 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
1-800-6 7-0982. The 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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14) REQUIREMENTS FOR ROOF COVERINGS. Roof coverings shall be applied in accordance with the applicable provisions of the current code and the
manufacturer's installation instructions.
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15) WIND LOADS- Roof coverings shall be designed and tested to withstand the maximum basic wind speed. The basic wind speed for Mason County is 85
MPH.
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16) 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
Bu NJ
Department prior to any further inspections being performed or approvals granted.
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17) Compliance with an approved Storm Water Plan shall be subject to an on site inspection, or inspections, by the engineer of record or an authorized
representative. Said inspection(s) shall be performed in accordance with the approved plan, and prior to any modification that would make a
determination of compliance impossible.
Inspection reports shall be submitted to verify all engineering requirements have been completed in accordance with the approved storm water plan.
Reports shall be submitted to the Mason County Department of Community Development prior to each corresponding inspection and final permit
appr Copies of all special inspection reports shall be made available at time of inspection.
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18) ALL SURFACE WATER AND POTENTIAL RUNOFF WILL BE CONTROLLED ON SITE AND SHALL NOT ADVERSLY AFFECT ANY ADJACENT
PROPERTIES NOR INCREASE THE VELOCITY FLOW ENTERING OR ABUTTING TO ANY STATE OR COUNTY CULVERTING/DITCHING SYSTEM
OR ROAD AY.
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19) Washington State Energy Code Compliance has been approved as follows:
Heat Type: Electric , Compliance Method: Prescriptive option II (25% glazing or less), Window(Max U-Factor):0.32, Skylight(Max U-Factor):0.50, Doors
(Type/Max U-Factor):0.20 or less, Wall insulation R-21, Floor insulation R-30, Ceiling Insulation R-49 standard, and Slab Insulation R-10.
In addition the following credit from Table 9-1 shall be completed: 6,small dwelling unit
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20) The ap roval of this project is subject to the recommendations and specifications outlined in the attached geotechnical report . All applicable
recommendations and specifications shall be applied to the development on this site. Any deviation requires stamped written approval from the registered
design professional responsible for the report/assessment, and may require special inspection by same. Structures and/or land modifications (grading,
cuts, fills, etc.) required in the geotechnical report may require a separate permit. The geotechnical report shall remain attached to the approved building
pla]:,,,
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BLD2011-0000J Please referto the following pages for conditions of this permit. 4 Of 5
s 21) An inspection performed by a representative of Envirotech Engineering, the geo-engineer of record, shall be completed on-site prior to the footing pour to
verify that earthwork and foundation installation activities comply with the Geotechnical report recommendations.
The special inspection report shall verify that Envirotech Engineering has assessed the bearing strata and that the footing is placed a minimum of 4' below
the existing ground surface.
In addition a final inspection report, prepared by Envirotech Engineering shall be required to verify that erosion control, drainage and final work is
completed in accordance to the Geotechnical report recommendations.
Reports shall be submitted to the Mason County Building Dept., PO Box 186, Shelton, WA 98584, prior to the footing and final inspections and available
for inspection.
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22) Owent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
Ag
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23) Appr dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
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24) Temporary erosion control measures must be implemented to prevent water wyali degradation of adjacent waters or properties. Silt fencing must be
installed and maintained until upland vegetation has become established.
25) All construction and demolition debris must be removed from the site after project completion. oper disposal of construction debris must be on land in
such a manner that debris cannot enter or cause water quality degradation of State waters. X �A/
26) Compliance with an approved Storm Water Plan shall be subject to an on site inspection, or inspections, by the engineer of record or an authorized
representative. Said inspection(s) shall be performed in accordance with the approved plan, and prior to any modification that would make a
determination of compliance impossible.
Inspection reports shall be submitted to verify all engineering requirements have been completed in accordance with the approved storm water plan.
Reports shall be submitted to the Mason County Department of Community Development prior to each corresponding inspection and final permit
ap v . Copies of all special inspection reports shall be made available at time of inspection.
X
This permit becomes null and void if work or construction authorized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at anytime after work is
commenced. 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 inspection.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 a d structure for review
'and
p in pecti n. l l
OWNER OR AGENT: V VAC/ DATE: � 6 - 1 I
BLD2011-00081 Please refer to the following pages for oo nd i tion s o f th is permit. 5 of 5
o
EXISTING PAVED
I TOP OF 35X SLOPE SCALE, 1 INCH BO FEET=
j S88'DRIVEWAY AP 1ACH :9' 39' E 678.79' j 0 20 40 80
i
AND RESERVE SEPTIC
DRAINFIELD AREA (SEE
DRAINFIELD DETAILS)
PROPOSED 1000 GAL s' W� 1 � - u ,�
I( PUMP TANKi
ROOF INFILTRATION LIMITS
PROPOSED 1200 GAL I
ROW ROW SEPTIC TANK
H y N I i PROPOSED 1 BE OOM _
a g III SECONDARY UNIT - 's 8 /
P
pi� EXISTING GRAVEL, i 1 '� L14 PPROXIMATE LOC TION)
A-v j SURFACED DRIVEWAY 1 �l
a rutj 1
and
ROOF INFILTRATION LIMITS
I , PROPOSED BEDROOM
SINGLE FA LY RESIDE
j (APPROX E LOCAT )-
;� lk
! TOP OF'60'/,+ SLOPE /
MAINTAIN`501+ SETBACK
ROOF INFILTRATION S PER GEOTECHNICAL REPORT. _
S88'15'00'E 697.
PROJECT/ OWNER/ LOCATION,
i WERDALL GEOTECHNICAL
REPORT ADDENDUM #1
X Yv_ AE' DAPPQ n
JEFF AND PAM WERDALL
PARCEL 12221 62 10001
MASON COUNTY DCD PLANNING MASON COUNTY, WASHINGTON
SITE PLAN REQUIRED TO BE ON SITE ENGINEER,
CHA GES SUBJET TO APPROVAL ENVIROTECH ENGINEERING
` 74 NE HURD ROAD
By ��1 360-275�9374HINGTON 98528
�W
SITE PLAN
• �,.s
Name2UNr �N M UU-ML rcel# a- A L Z..1 OMO I 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)V 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.
XYOt 9— Owner/ gent/Contractor(circle one)Date: - -`
Page 2 of 2
Namely PF111\ WE"L�arcel# IlaI 6a I l..OW I 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
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 =
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)
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. 1 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 I of 2
MASON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION Cog,
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 MW-ef b t. �+ i+ Company Name B ENA i KI1IFT[!fly '�L
Mailin Address D Mailing Address 1 d , �Y- �S
City '� Stat Zip Cocle �- City S L State LUR _Zip Code'N5�Z
Phone L- ��� ��� Other Ph. b �L Phone 3LJ �-1-1 0�11 Other Ph3l✓a SLR'
Lien/Title Holder Contractor Reg. # F ` xp. 10 Qj JV
E mail address -1e—RRIKI-IP '�E Mail Address
Drivers Lic. #WUU LqLSL'. DOB L 'S Drivers Lic.#UE9,0K LLA6-�; DOB Sl1
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well-Water System Name of Water System
PARCEL INFORMATION - 12 Di it Parcel No Fire District
Legal Description t--,OV 7 L07 A 'f EEL:-) E R LV Llli� 1)kA)S3"Z / �3S
Site Address (Please include street name, street number and_ciit C_- 1_. RT d�- _
Directions to site 1/I m\l - ELM [ARTCJ��->,� C)m H t,LL
Will timber be cut and sold in parcel preparation? Yes 0o
Is property within 200' of Saltwater Lake River/CreeVBIuff
- Pond
Wetland Seasonal Runoff Stream Slopes r s > 15%
Is this permit submittal th result of a Stop Work Notice,Correction Notice or other enforcement action?Ye!(KO)
TYPE OF JOB - New V Add Alt Repair Other PRIMARY RESIDENCE,& SEASONAL ❑
Use of Building Describe Work ivn 1 rm c,T
No. of Bedrooms I No. of Bathrooms_I Square Footage- 1 sit or ��� 2nd Floor
3rd Floor Basement Deck Covered Deck �� Other Sq. ft.
Garage i�b Attached x 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 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 accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROOF OF CON IN ATION O q IS BY MEANS OF A PROGRESS INSPECTION.
x Date:
ner Owners Representative/Contractor indicate which one
FORbrftdlAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee / ''' Site inspection
Plan Review Fee i 4/ 9,16.9,5 EH Review Fee
Plumbing & Base Fee 7 '¢ '7" Planninq Review Fee
Mechanical & Base fee ,-2 O g Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ / Sr0 5 ,, TOTAL FEES
I
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t 32
PERMIT NO.
MASON COUNTY
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 ORMATION CONTRACTOR
Owner —1 L. Z.✓ '" Company Name L
Mailin AddrPSS Mail d r ss
City State LNS Zip Code >� City State Zip Code
Phone Other P 3 l 1 D ����b!o Phon Ph S b�
1 I� TV",� - Contractor Re i
Lien/Title Holde 9 A
E mail address 1 _ V C-30r� E Mail Address _ ��
Drivers Lic. L DOB -�. -9 Drivers Lic.#� �LI6SLEDOB L,—S 'S(-1
SEPTIC INFORMATION - Connect to New Septic V Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No _ Fire District
Legal Description 1
Site Address (Please include street name street number and city) =
Directions to site / /---) �l-F-rr ��Brn Tk f' DMITT— V'y N I`� j l I
Is property within 200' of Saltwater Lake River/ �ond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
TYPE OF JOB - New,/— Add Alt Repair Other Use of Building 1 v
Location of Fixtures/Units - 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type-.Electric LPG_Natural Gas _Heat Pump_
Toilets Type of Unit No. of Units Fees
Bathroom Sink V Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan f
Water Heater �� Propane Tank
Clothes Washer Gas Outlets
Kithen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
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 party in interest regarding this application or the work proposed in the application,1 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 empickyees of Mason County access to the above described property and structure for review and inspection.
PR OF ONTINUATION F W K BY MEANS OF A PROGRESS INSPECTION.
X Date
r O ners 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
Plumbing & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES