HomeMy WebLinkAboutBLD2020-00317 SFR ADU2020-00003 - BLD Application - 1/26/2024 • MASON COUNTY COMMUNITY SERVICES Permit No:'jld 2Zb;o • 66-- )i
PERMIT ASSISTANCE CENTER: .. C E
'� " •BUILDING •PLANNING•PUBLIC HEALTH•FIRE MARSHAL I '`�—
615 W.Alder Street,Shelton,WA 98584 S�,• ilton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone NIAR 19 L '
* 1'3elfair. (360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATI
W. Alder
PROPI IZTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: A ao /Y rJS C'V\ NAME: 5-r If t/VY�L°i✓
MAILING ADDRESS: ?0 0-15 MAILING ADDRESS:
CITY: a rapeul q-tv STATE: w t - ZIP: CITY: STATE: ZIP:
PHONE#I.- I C9 0(0 - qQ PHONE: CELL:
PHONE#2: 906 pt[? - 001s' EMAIL
EMAIL:�� n ,j�_�fQU aof/oo/�• L&I REG# EXP. l l
PRIMARY CONTACT: OWNER CONTRACTOR❑ OTHER❑
NAME S"�� "I c EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL�rI6O�
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 3 -/0 -0 0q p v ZONING
LEGAL DESCRIPTION(Abbreviated) ej- 4 8L --1D 1 FIRE DISTRICT
SITE ADDRESS CITY W
DIRECTIONS TO SITE ADDRESS L_O
S
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NOX
IS PROPERTY ITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER LAKE❑ RIVER/CREEIC ❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑
TYPE OF WORK: NEW)< ADDITION ❑ ALTERATION ❑ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) ?,-\r la',o y I/<Q e NGC r
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS_ NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg), YES(Part[s]of Bldg) ❑ NO ❑
DESCRIBE WORK h
SQUARE' FOOTAGE:, (proposed) �Q�CC-
I ST"�"I 6C q. ft. 2ND FLOOR sq.ft.' 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK Y/�, sq. ft. COVERED DECK sq,ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq. ft. Attached❑ Detached❑ CARPORT r sq.ft. Attached� Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE ODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH: '5(N6 01d��'•Ooo20
SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW❑ EXISTINGO
PLUMBING IN STRUCTURE? YES NO ❑ Ifyes, attach completed Water Adequacy Form
PERIMETER/FOUNDATION DRAINS PROPOSED? YES,, NO[] EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS /
OWNER acknowledges that submission of inaccurate information may result In a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal
representative, represents that the Information provided Is accurate and grants employees of Mason County access to the above described property
and structure(s)for review and inspection. This permitiapplication becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 180 days. .-
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON
COUNTY CODE 14.08.42)
Signature of OWN R(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED D TE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT 1)e-t` �31
I
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
MASON COUNTY
COMMUNITY SERVICES RECEIVE
D
Building,Planning,Environmental Health Community Health
MAR 19 2020
Physical and Mailing Address: 615 W Alder St.,Bldg 8, Shelton, WA 98584
Shelton Phone: (360)427-9670 ext352 •b Fax (360)4274798 F IF) Vly Alder Street
PLUMBING & MECHANICAL PERMIT APPLICATION Permit#: ZId2n?D
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: 5LUg4 i; t \�(Scw\ NAME: �J
MAILING ADDRESS: PLO a/r' MAILING ADDRESS:
CITY: G L(' Yrd r et u STATE: ZIP: 9E CITY: STATE: ZIP:
15t PHONE: 206 PHONE: CELL:
2nd PHONE: �Dki G - 00 C� EMAIL
EMAIL: t! _0 /Svc 90 d- L&I REG# EXP. I I
PARCEL INFORMATION:
PARCEL NUMBER (12 Digit Number): 1�a3 j4 -r?9�G Zoning: LAP')
LEGAL DESCRIPTION (Abbreviated): -PC,1- L Q
SITE ADDRESS: G+T-Y: 9X'S_,7
DIRECTIONS TO SITE ADDRESS: C
� t
TYPE OF JOB/WORK: NEW ADD ALT REPAIR OTHER
USE OF BUILDING ` \ K C e-
PLUMBING FIXTURES MECHANICAL UNITS [J Electric in-wall heaters(no fee)
Type of Fixture No. of Fixtures Fuel Type Fees Type of Unif No. of Units Fuel Type Fees
Toilet(s) Furnace G/LPG]
Bathroom Sink(s) Heat Pump / G/LPG]
Bath Tub(s) o Ductless H.P. [E/G/LPG]
Shower(s) Spot Vent Fan
Water Heater(s) / [E/CA05Propane Tank 1-9al.]
Clothes Washer(s) J /LPG] Gas Outlets) _
Kitchen Sink(s) Heat Stove
Dishwasher(s) Kitchen txhaust Hood
Hose Dryer Vent
0therbVY44) Solar Panel
OtherawJ9 Cf"K ] Other
3,kGKF'c a✓ Plumbing Subtotal Mechanical Subtotal
Plumbing Base Fee Mechanical Base Fee
Final InspecJjnn Fee Final Inspection 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 contractor.I further declare that I am entitled to receive this permit and to
do the work as proposed.I have obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this
project.The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above
described property and structure(s)for review and inspection.This permittapplication becomes null&void if work or authorized construction is not
commenced within 180 days or if construction work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS OF
INSPECTION.INACTIVI OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
x
Signature f Applicant D
x �r,tur h i���`�ri✓1 Owner wners Representative/Contractor
Print Name c e one)
DEPARTMENTAL REVIEW APPROVED PAT)E DENIED DATE TAGS/NOTES/CONDITIONS
O Building
O Fire Marshal
O Permit Tech (OTC permit only)
Visil us on-line: http://www.co.mason.wa.Lls/conrI)unilty_dev/ Rev:3/08/201.7
Name �Ok,4 el# I A"9—10 BLD# 8
G
Mason County
Department of Community Development MAR 19 2020
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
100 W. Public Works Dr
Shelton.WA 98584
If this development has,or will have,a septic/drainfield system you may need to contact Mason County Division of
Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or
any other, parcel. You may also wish to consult with the septic design professional involved with the project. Mason
County Division of Environmental Health can be reached at:
Phone: 360-427-9670 ext 400
415 N.6th St—Bldg#8 lower level
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. 2 /�
X �— Owne Agent/Contractor(circle one)Date:
Page 2 of 2
Name lWfeel- Parcel# /��,3p2 —/19 —(go?o BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 1 of 2)
P%adeor
ounty Code,Title 14,Chapter 14.48 a stormwater site plan is required whenever a building application is
midential development, or redevelopment',with more than 2,000 square feet of impervious surface2.
'Rent means,on an already developed site,the creation or addition of impervious surfaces,structural development
including con ction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not
part of a routine aintenance activity,and land disturbing activities associated with structural or impervious redevelopment.
'Common im ervious rfaces include,but are not limited to,rooftops,walkways,patios,driveways,parking lots or storage areas,
concrete or asphalt pavin gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the
natural infiltration of storm ter.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
To Calc ate Impervious Surfaces Please Complete This Table
Surface Type Length Width = Area *All dimensions in feet
Buildings X
X = Measurements for buildings are taken at the
perimeter of the farthest projections(example:
X = 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 = \nyaved, gravel or packed area per definition
above table
X =
Others X =
X = If the tots ' pervious area of the proposed site
X = developmen 's greater than 2000 square feet a
Small Parcel rmwater Site Plan is Required
Total Impervious Surface Area(sum of all areas) V/10
If the Total Impervious Surface Area is LESS THAN 2000 Square Feet,please read,ackn led a and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this opmrit activity.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order o4irmit 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 Arealjs GREATER THAN 2000 Square Feet, please read,acknowledge and sign
the information provided on page 2 of 2.
Page 1 of 2
�� 2�ZD - D000� • ' . '
PLANNING
I d ao1-7 - OCH58
PLANNING. RECEIVED
ALL SETBACKS ARE MEASURED
FROM THE FURTHEST MAR 19 2020
/1►RCHITEGTS
PRQ.JECTION OF THE BUILDING ADIAGENT PA pL�c _
RCEL �> •• .• `..
615 W. Alder Street. / :..`p:a � 196:0;.:
can)
(3ea1 tx1�1!!.I pn1►nn.l
— — N 86'3593'E L I ` '
EXISTING
\ EXI5TING `95'93_ _ NELSON'S :•
BUILDING
RESIDENCE.
... _ GHERE GO wlvEHraAT P RONT EIGHBOR'S HOUSE
OR X �+ , :MAIN HOUSE
. / SYSTEM !? _ •N
�u LOCATION.SEE 5EPi1G I u7 ( — I F LINE O O/ DRAYVINGS.AMER (J --- -- — �js �y / 520 E.CRONQUISTRD
SEPARATE PERMIT) / ALLYN,WA
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DRNBNAY / I (3 B BEDROOMS
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N _
70 f /G f C?o, cR S °2 112' cis 36"
ADJACENT PARCEL vry / �I
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NORTH .0
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� ARCHITECTURAL SITE PLAN .�I� ... . . .
old M2-0 �^
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NOTE THIS ORAWNG DOES NOT REPRESENT A SURVEY PERFORMED UNDER THE DIRECTION OF A 1JGBd5ED RE SURVEYOR. THE BEARINGS k I i s I r L 9
AND DI57ANGE5 SHONW A APPROXIMATED AND THE BA55 OF BEARING 5 ASSUMED.vmTICAL DATUM 5&SO ASSUMED. '
APPROVED ® �,. . .
S ! r• .v
WOM COUNTY OCD PLANNING �'`:;`
Sft'E PL,.AiII REOYIREJ TO BE ON SITE ' .. . .
UIBJE'T TO APPROVAL.
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For Mason County Permit Center use:
MASON COUNTY Abu_
COMMUNITY SERVICES - woo
ReWd by Planner.
Building,Planning,Environmental Health,Community Health
615 W Alder St.,Bldg 8,Shelton, WA 98584
Dare Stamo Recv'd:
Shelton Phone: (360)427-9670 ext 352 ❖ Fax (360)427-7798 :
a
ACCESSORY DWELLING UNIT PERMIT
RECEIVED
(Special Use Permit with ADU criteria) `
t' MAR 19 2020
615 W. Alder Street
Permit and Fee:
❑ Special Use Permit (DDR)—application fee: $240.00
*If ADU is within 200'of a shoreline you must apply for a Shoreline Substantial Development Permit(SHR)-fee:$880.00
-Environmental Health fee: $ 1 11) .00R
A "Special Use" is one that possesses unique characteristics due to size, nature, intensity of use, technological
processes involved, demands upon public services; relationship to surrounding lands, or other factors. The
purpose of this application is to provide for adequate oversight and review of such development proposals, in
order to assure that such uses are developed in harmony with surrounding land uses, and in a manner consistent
with the intent of the Development Regulations for Mason County; Ordinance No. 82-96. Acceptance of this
application by Mason County does not guarantee approval of request.
Applicant(s) Name: 45LeItse -f1 Ne�`.ram
Mailing Address: P. 0 • Bey 0/s-
67
ew
Phone: 906 - qo - %l,� E-mail: yL/V e /S-on g�o U-11dO,4�LQltl
Property Owners Name: (if different than applicant) ��'�1�0 lq
Site Address: �f f1 w �-+�
Brief Legal Description: �C L �� D�-�d /�JIj �• t S
S
Tax Parcel #: - 0 Zoning: /2
Project Description:
u w o_cS
T
,0,e_w J3 -ecQ v-,rjc�h oyA e- cv h 7_-riff a, ca&l) wad'
Rev.January 2018 le ADUPermit Page 1 of 4
❑ SITE PLAN CHECK-LIST Please provide a site plan that includes the following:
d Indicate Scale and North Arrow.
EA Property line dimensions, easements, and right-of-ways.
The location of all existing and proposed structures. Include square footage of existing and proposed structures.
Setback distance, in feet from all property lines and structures.
❑ Existing and proposed road access to and from the site.
Parking spaces.
Location of OnSite Sewage System (OSS) components (including tanks, drainfields, reserve areas, etc.)
Location of existing and proposed wells,within 100ft. of property, shown with 100ft. radius.
❑ Location of existing and proposed waterlines.
❑ Steep bluffs, wetl nds, str4ams, and bodies of water.
❑ Surface and storm water run-off routes.
Mason County Code Title 17.03.029 requires the following criteria to be met for
consideration of an Accessory Dwelling Unit (ADU) Permit:
ACCESSORY DWELLING UNIT(ADU) REQUIREMENTS YES NO INFORMATION
1. Is the ADU in a shoreline jurisdiction? e_q GLSe— Lf1 I e-
Please inquire with Mason County
1 a Are you in the Flood Plain? ❑ F] CommunityServices staff, if unsure.
2. Will the owner of the lot reside in either the principal z ❑
residence or the ADU?
3. Will the ADU be located within 150 feet of the principal ❑
residence or will the ADU be a conversion of an existing
structure i.e. garage)?
4. The ADU cannot exceed 80 percent of the habitable area 1J7 ❑ i�CQ
of the primary residence, or 1000 sq.ft., whichever is
smaller. Will your proposed ADU meet this criteria?
Please inquire with Mason County
5. Will the ADU meet all setback requirements? ❑ Community Services staff, if unsure.
Please see last page of this packet
6.Will all applicable health district standards for water and ❑ titled"ADU Environmental Health
sewer be met by the ADU? Requirements"
Rev.January 2018 ADUPermit Page 2 of 4
7. Recreational vehicles are not allowed as ADUs. Please
confirm (with YES)that you are not submitting a
Recreational vehicle for review.
8. Your property will only have one 1 ADU?
9. You have provided an additional off-street parking space El
for the ADU?
(Ord.108-05 Attach B.(part),2005)
❑ On a separate piece of paper(#of pages: ), state your reasons for requesting an Accessory
Dwelling Permit and be sure to address the following six criteria. Your request will be evaluated based on
these criteria and the Accessory Dwelling Unit Requirements from the previous section.
1. Will the proposed use be detrimental to public health, safety, and welfare?
2. Will the proposed use be consistent and compatible with the intent of the Comprehensive Plan?
3. Will the proposed use introduce hazardous conditions, at the site,that cannot be mitigated through appropriate
measures to protect adjacent properties and the community at large?
4. Is the proposed use served by adequate public facilities,which are in place, planned as a condition of approval
or as an identified item in the County's Capital Facilities Plan?
5. Will the proposed use have a significant impact upon existing uses on adjacent lands?
6. If located outside of an Urban Growth Area,will the proposal result in the need to extend urban services?
Applicant's Signature Date
Rev.January 2018 ADUPermit Page 3 of 4
MASON COUNTY
COMMUNITY SERVICES
� Buiidmg.Planning,ratvaonmental Healtt4Community Health
ADU ENVIRONMENTAL HEALTH REQUIREMENTS
YES NO INFORMATION
1.Will the ADU be served by an EXISTING Onsite Sewage System(OSS)? 3W6 ok I�-00 00
OSS's are sized off bedrooms.
Refer to the onsite sewage records
1(a). Total bedroom count from existing and proposed connected structures on file with Mason County to find
match the approved OSS records on file? your OSS approved size. Ifbedroom count exceeds system size,
contact a licensed septic designer
for upgrade options.
OSS application and design permit
2. Will the ADU be served by a NEW Onsite Sewage System(OSS)? must be submitted and approved
prior to EH approval of ADU
permits
-Foundation to Drainfield(s):I Oft
-Foundation to Reserve Area(s):
X
loft
3. Will the ADU meet all setbacks to new or existing OSS components? Foundation to Septic Tank(s): 5ft
Down gradient
Foundation/perimeter drains must
maintain 30ft to Drainfields.
Attach a signed Sewer Adequacy
4. Will the ADU be served by a NEW or EXISTING sewer connection? Form from Sewer System Manager
to this application.
5. Will the ADU be served by a NEW or E G public water system A Attach a signed Water Adequacy
(over 3 connections)? n Form from Water System Manager
to this application
6. Will the ADU be served by an EXISTING private well? �[
/\ Well must be permitted and
7. Will the ADU be served by a NEW well that is not constructed yet? constructed prior to EH approval of
X ADU permits.
Mason County Code Title 17.03.029 requires EH approval prior to approval of ADU permit.
Environmental Health Review Pre-approval: -
Comments: ka- a L.L_ APPROVED
JUN 0 3 2020
MASON COUNTY ENVIRONMENTAL HEALT
Guild;
(EH approval stamp with Initials of EHS)
ADUPermit Page 4 of4
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$ Ventilation - Fan Specifications (IRC M1507,) shall be high effic�
luminaries are cor
athrooms&Laundry Rooms 50 CFM mina @.25"w.g. photosensor or inE
ther Wet Rooms 50 CFM min. @.25"w.g. All fluorescent fixtL
1 - itchen 100 CFM @.25"w.g. or T-12 lamps). IE
Construction must match all design/details/specifications of (hole House Fan Tested at.25"w.g., 1.0 sones or less @ .1"
n Architectural/Engineering structural requirements OR a stamped g.controlled by a 24-hr clock timer capable of continuous operation,
t letter of approval must be provided from the design professional
2075602 MASON CO WA
06/12/2017 02:32 PM NOTCE
NELSON #104112 Re. Fee: $73.00 Pages: 1
IIIIII IN 111111111 IN 1111111 III 11111111111111 IN
Return To:
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NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned, certify that the water source located on parcel situated in Mason County,State of
Washington,herein described. /
OR
Subdivision Division Lot Range Township Section
And having the Tax Parcel Number of: L j�_°�3-1--/—O --_0A G U
Has been designated to serve a source of water to the following parcels situated in Mason County, State of
Washington; herein described: (abbreviated legal description and tax parcel numbers(s)of property(ies)affected )
OR
Subdivision Division Lot Ran a Township Section
And having the Tax Parcel Number of:1 -- --_0�(�
OR
Subdivision Division Lot Range Township Section
And having the Tax Parcel Number of:�[ 3 - -- 0410
The system owner is responsible for keeping this system in compliances
The name of the system is N f__LS m U)CLf->✓'4~
This system is designed to provide for two services. Planning and design approvals must be obtained
from the department prior to expanding beyond this number of services. Additionally, a water right,
obtained from the Department of Ecology, is required if the water system exceeds exemption standards.
This system (has/has not een granted one or more waivers from specific provisions of the
r!9yLlabqns.
Signa re 6ignature
State of Washington )
County of Mason )
I,the undersigned , a Notary Public in and for the above named County and State,do hereby certify that on this
day of 3w�� 20�, Suss n h)�Iso� n.r.ct \)i cnd"N M%e sonall appeared before
me,who is known to be signer of the above instrument, and acknowledged that he(she)( ey igned it.
GIVEN under my hand and official seal the day and year last above written.
r„
Notary Publ in, d for the State of Was 'ngton
residing at KeeyL -
Notary Public My commission expires: Z
State of Washington
JESSICA ANN DANIELS
My Appointment Expires Dec 26,2017
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LIST OF ADJACENT PROPERTY OWNERS' MAILING ADDRESSES
WITHIN 300 FEET OF YOUR PROPERTY BOUNDARIES
Addresses are to be obtained from the Mason County Assessor's Office, Bldg. 1, Second Floor.
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