HomeMy WebLinkAboutCOM2023-00096 Restaurant - COM Application - 10/16/2023 MASON COUNTY COMMUNITY SERVICES Permit No v
PERMIT ASSISTANCE CENTER:
. •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
-• 615 W.Alder Street,Shelton,WA 98584 0 C T 16 �023
Phone Shelton: 360 427-9670 ext.352•Fax:(360)427-7798 Phone
Behair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION 615 W. Alder Street
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: 1 NAME:
MAILIN DRESS: MAILING ADDRESS:
CITY:`] STATE: l ZIP: CITY: STATE: ZIP:
PHONE#I: y. PHONE: CELL:
PHONE#2: Z EMAIL
EMAIL: G# EXP.
PRIMARY CONTACT: OWNER❑ CONTRACTOR❑ OTHER❑
NAME 4ph Vl EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE • CELL
PARCEL INFORMATION: c^ I M
PARCEL NUMBER(12 Digit Number) 44=12"50 " 11 W 3 ZONING
LEGAL DESCRIPTION( bre�viiatf d) FIRE ISTRICT
SITEADDRESS ,�A3&41 . U C1 U19&4 101 CITY �SYP0I
DIRECTIONS TO SITE ADDRESS Ili 4
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑ SNOW LOAD: psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all Mai apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ AL RATION/ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg, )r&&
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(nV le Bldg)❑ YES(Part[,]of Bldg)❑ NO❑
DESCRIBE WORK
SQUARE FOOTAGE:(proposed)
1 ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK 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*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
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 permit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 18o 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
1 2 COUNTY CODE 14.08.42)
XAel. I.- ff" .
Signature of W ER M�es%i:ned by the OWNER Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
n��,,/��•
MASON COUNTY COMMUNITY SERVICES Permit No: r &V
_ e 4p
PERMIT ASSISTANCE CENTER: RECEIVED
•BUILDING •PLANNING •FIRE MARSHAL
615 W. Alder St- Shelton, WA 98584 OCT 16 2023
www.co.mason.wa.us
Phone Shelton: (360)427-9670 ext. 352• Fax:(360)427-7798
go Phone Belfair(360)275-4467• Phone Elma:(360)482-5269 615 W. Alder Street
PLUMBING & MECHANICAL PERMIT APPLICATION
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:Fjord Holdings NAME:John Hansen
MAILING ADDRESS:213 SE Stotsbery RD MAILING ADDRESS:213 SE Stotsbery rd
CITY:Shelton STATE:wa ZIP:98584 CITY:Shelton STATE:wa ZIP:98584
I S`PHONE:360-229-6981 PHONE:360-427-5599 CELL:360-229 6981
2n1 PHONE:360-427-5599 EMAIL :JOHNANDRCHEL@COMCAST.NET
EMAIL:johnandrachel@comcast.net L&I REG# EXP.
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Nuniber):422125011003 Zoning:
LEGAL DESCRIPTION(Abbreviated):Hoodsport blk. 11 Lots 5-6&N1/2 alley adj 5
SITE ADDRESS 24341 N Highway 101 CITY}ioodsport
DIRECTIONS TO SITE ADDRESS:
Hwy 101 north to hoodsport first lot to left passing finch creek
TYPE OF JOB:
NEW=ADD=ALT=REPAIR=OTHER=USE OF BUILDING
LOCATION OF FIXTURES/UNITS— IT FLOOR=2ND FLOOR=BASEMENT=GARAGED OTHER
PLUMBING FIXTURES(SHOW NUMBER OF EACH) MECHANICAL UNITS
Type of Fixture No.of Fixtures Fees Fuel Type:Electric=LPG�atural Gas=Ductless=
Toilets rMa4a, Type of Unit No.of Units Fees
Bathroom Sink 1 molrut. Furnace
Bath Tubs Heat Pump
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer Gas Outlets • ��
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood I -
Hose bibs Dryer Vent
Other Solar Panel
Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER acknowledge 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 permit/application becomes null&void
if work or authorized construe is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF
OF CONTINUATION.-OAH)JS PERMIT IS BY MEANS OF INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS
WILLIIINNy.AUDATE THE 'PPLICATION.
Sig at of Owner to
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
Rev:1/27/2016 JBN
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DESCRIPTION OF RECORD LEGEND SEE QUITE TITLE ACTION
FJORD HOLDINGS LLC: PARCEL NO. 42212-6 0-110 03: LOTS 6 AND 8, • - sEf 15 IROx BAR-_lI�PLA.4ITC SUPERIOR COURT CAUSE N0. 23-2-00535-23
BLOCK 11, PLAT OF HGODSPORT, VOLUME 2 OF PLATS, PAGE 8, CAP 'HO Is 16869'
RECORDS OF MASON COUNTY, WASHINGTON. TOGETHER WITH THE 0 - FOUND AS NOTED -------------
-_ N FINCH CREEK RD
NORTH ONE-HALF OF THAT PART OF VACATED ALLEY ADJOINING SAID (P)= PLAT '
LOT 5 ON THE SOUTH. TGROVE 9 T--------------------
(M)- MEASURED O FOUND CONCRETE NAIL IN PAVEMENT SET BY MERLE B. LINE TABLE
FJORD HOLDINGS LLC: PARCEL NO. 42212-50-11004: LOTS 7 AND 8, o= umnT POLE LINDGREN AS SHOWN ON SURVEY VOL 1, PG 178. REPLACED / IN
BLOCK 11, 2 OF PLATS, PAGE 8, UNDERGROUND CABLE �i WITH#6 IRON BAR W/CAP-HOLMAN IS 16663' (MARCH, 2022)
RECORDS MASON COUNTY. TOGl;Tfl N WT4'44'W 12123(IQ /
VACATED SOUTH
ADJOINING 10 FEET OF STREET ADJOINING SAID LOT 8 ON THE Is- LANDSCAPING AREA t
NORTH. O - FIRl=DRANT / O VACATED - /
s - SPIGOT O %
ILA MA YOUNG FOOD INC: PARCEL NO. 4 2 212-60-11001: LOTS 1, 2, 3, ® - WATER METER / g -------L----- pywel_3- 07.39
AND 4, BLOCK 11, PLAT OF HOODSPORT, VOLUME 2 OF PLATS, PACE 8, m- IRRIGATION BOX
RECORDS OF MASON COUNTY, WASHINGTON. TOGETHER WITH THE 0= TREE 08/13/2024
NORTH ONE-HALF OF THAT PART OF VACATED ALLEY ADJOINING SAID / ;; IS �e Oo /
LOT 5 ON THE SOUTH, ALSO TOGETHER WITH ALL THAT PORTION OF / S Parking
THE VACATED NORTH 20 FEET OF CUSHMAN AVENUE ADJOINING SAID / $ APPROVED
LOT I ON THE SOUTH. / k It �$� J�� MASON COUNTY DCD PLANNING
RECORDS OF MASON COUNTY, WASHINGTON // b -- 507T NEWAV
TOGETHER WITH AND SUBJECT'I'O EASEMENTS. RESTRICTIONS, 50'Setback 40' l '
RESERVATIONS AND COVENANTS OF RECORD. / B s ptic 30 0 gallon d /Digitally
from creek ., A signed
NOTE O ;�a� Park ; �0' s / Rued
PLAT OF HOOD HOODSPORT es �'' REFERENCE SURVEYS Parking / /
MONUBRASS
UMENT SW / Ot` SEE PLAT OF HOODSPORT Existing septic g /This is a non- 0
CORNER LOT 15 / I VOLUME 2 OF PLATS, PAGE 6 8 c 100, conforming 0 BLOCK 11 (MARCH, / I VOLUME 1 OF SURVEYS, PAGE 178 6 `�- ENE setback
2022) A9 SHORN ON /
SURVEY022) BY MERLE / I s ----- -------- �/ structure. This
B. LINDGREN VOL L / I I SEE ALSO UNRECORDED SURVEYS BY a n
PG. 178 // i SWIFT. BRACY k THOMAS. $ LOT 5 o .� approval is for the
11LOT 15 j LOT 14 LOT 13 LOT 12 I LOT 11 i LOT 10 I LOT 9 � HUII.DING Is % use of the existing
Pl- -----1----9 aers'4Li i7a.oD(P517124�C�---1-------_L_ / building only.
EA
------ /
CID �y---,�.__-_-_ _ AY
1 2 AIJ.EY 2Q,p(P) �•s IIM4'44•s e7.szt(q sl:4ts-(1Q,„
Go 16' VACATED ALLEY �-18(c) �
------------------------- OD rP" �/ a,NEW DESCRIPTIONS ---------__=__- -
FOORID HOLDINGS BLOCK
11, PPARCEL NO. HOODSPORT,
41?FOUND LEANING 42 LOT 4 0%_ !' GRASS 1 O / 4",1
LOTS 6 AND 8, BIOCK Il, PLAT OF HOOII3PORT, VOLUME 2 OF PLATS, PAGE 8, RECORDS OF
MASON COUNTY, WASHINGTON. TOGETHER WITH THE NORTH ONE-HALF OF THAT PART OF \'� i 7-
9 4- IRON PIPE LANDSCAPE /
VACATED ALLEY ADJOINING SAID LOT 6 ON THE SOUTH. / CAP RAILROAD
'LINDGREN Is 4 BORDER ROCK '� / 4� NW 1/4, 3W 1/4
AND THAT PORTION OF LOTS 1, 2, 3, 4, AND THE VACATED AId.E$ BLOCK 11, OF THE PLAT OF A -\.�
1230p' SOUTH 0.46'----- 4 I
HOODSPORT, RECORDED IN VOLUME 2 OF PLATS, PAGE S. RECORDS OF MASON COUNTY, AND 1.19' EAST. � -------------
WASHINGTON, LYING NORTHERLY OF THE CENTERLINE OF FINCH CREEK AND EAST F.R1.Y OF TIC �d
WEST LINE OF LOTS 5 AND 6 OF SAID BLOCK 11 EXTENDED SOUTHERLY TO THE CENTERLINE g PIIDNOT TING.
OF SAID CREEK ACCEPTED LOT 3
RECORDS OF MASON COUNTY, WASHINGTON
OF TOGETHER WITH AND SUBJECT TO EASEMENTS, RESTRICTIONS, RESERVATIONS AND COVENANTS b ------------------------------ 10, /
PS 0.20 /
MA ILA YOUNG KOREAN FOOD INC: PARCEL NO. 42212-60-11001 73W,T4LO AC p 2 SEU12., . ., It 4 W.
LOTS 1, 2, 3, AND 4, BLOCK 11, PLAT OF HOODSPORT, VOLUME 2 OF PLATS, PAGE 6, RECORDS gF3 / Q
OF MASON COUNTY, WASHINGTON. TOGETHER WITH THE SOUTH ONE-HALF OF THAT PART OF 'T0'T� % O,
VACATED ALIKY ADJOINING SAID LOT 4 ON THE NORTH, ALSO TOGETHER WITH AIL THAT
PORTION OF THE VACATED NORTH 20 FEET OF CUSHMAN AVENUE ADJOINING SAID LOT 1 ON -------'-----------------
THE SOUTH. MA ILA YONG KOREAN FOOD INC. / L.
EXCEPTING THAT PORTION OF LOTS 1, 2, 3, 4, AND THE VACATED ALLEY, BLOCK 11. OF THE PO BOX HOODSPORT, a !F
ARCELNO. 42 98648 O SCALE: 1' - 20' -
PLAT OF H001)SP011T, RECORDED IN VOLUME 2 OF PLATS, PAGE 8, RECORDS OF MASON pARCII,N0. 42212-60-I100L �v I 0 20 40
COUNTY. WASHINGTON, WAL,EASTERLY OF THE WEST LINE LYING
GLOTS NORTHERLY 8 O OF F SAID B OU EXTENDED SOUTHERLY TO OF FINCH CREEK AND MAT 1 �=501
THE CENTERLINE OF SAID CREEK �, T0M41,WKo
RECORDS OF MASON COUNTY, WASHINGTON VACATED NORTH 20'
TOGETHER WITH AND SUBJECT TO EASEIINN'TS, RESTRICTIONS, RESERVATIONS AND COVENANTS LAKE CUSHMAN ROAD EQUIPMENT AND PROCEDURES 22-090.DWG
OF RECORD. 8 t1a'24'44'1 7171(C) Outdoor seating MW M P10=111M YER= zz-Oso.Asc
EH Setbacks 1! EH APPROVED URVEY HOLhfAN & ASSOCIATES
PNOlp.®DXAL LAND SURY91DR9
A. DrainfieldlReserve requires 10'setback from f00tln ountlatlOns ME)YIP COIL 1r MT ale A BEMW RIDE BY JR OR Rhonda Thompson 0 8/1 312 01 2 AP.C.BOX 237E
q 9H MMR Mr DML?VN Dr a1111M2luNce EM=N31}OSLmR9 FOR SEMM14 a 98684
B.)Septic tank(s)requires V setback from all footing/foundations OF T=SDBraf N69NDOW AC!'AT rM MMUMr OF (WO)42e-2wo PRDM tmoom
C.)No foundation/Perimeter Drains within 308,downgradient of p;q]?D ITOLPP(C;S.9C....................... FJORD HOLDINGS LLC Dnr BY ma JOB Na
DrainfieldlReserve area 1tA•ye,.QU NG JPR.W.NQI?utc.,...,••..•.,•. MA MA YONG KOREAN FOOD INC cMF AUG, 2Ozs 22-Gso
D.)No Cut Bank(s)(greater than 5ft and over 45 degrees)within AUGUST, IN
50N,down gradient of DrainfialdlReserve area �'''' z3'' NW 1 4, SW 1 4
DANIM F.JVZM N C�A^ITE Na.18ea1........ SECTION 12, TOWNSHIP 22 NORTH, RANGE 4 WEST, W.M. ®�DCH �j 1- - 20' agar 1 OF I
MASON COUNTY COMMUNITY SERVICES Permit Zorn 20Z3 • ��
PERMIT ASSISTANCE CENTER: RE^(v:E I\
� •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL �/
FU
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352-Fax:(360)427-7798 Phone OCT6 2023
Belfair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION 1 treet
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMA
NAME: I NAME:
MAILING DRESS: MAILING ADDRESS:
CITY: STATE: ( ZIP: 9EmEtl CITY: STATE: ZIP:
PHONE#I: PHONE: CELL:
PHONE#2: Z EMAIL:
EMAIL: nAL11MG# EXP.
PRIMARY COaACT: OWNER❑ CONTRACTOR❑ OTHER❑
NAME J 4p y) EMAIL
MAILING PRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION: ��^^ M
PARCEL NUMBER(12 Digit Number) �ZZ 12-�56 ~ 11 W 3 ZONING
LEGAL DESCRIPTION(Aibbreviatr
) FIRE
UI_LZ STRICT
SITE ADDRESS 34 Gt (d..Y4 j 101 CITY Si(1'S
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES[] NO❑ SNOW LOAD:_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❑ AL TION/ REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Dc.)_ fLSiio AC(a(+
IS USE: PRIMARYX SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Pan[s)ofBldg)❑ NO❑
DESCRIBE WORK
SQUARE FOOTAGE:(proposed)
1 ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.fL OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached❑ CARPORT sq.ft. Attached❑ Detached❑
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGEISEWER SOURCE: SEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO❑ Ifyes,attach completed Water Adequacy Form
PERIMETERTOUNDATION 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 permit/application 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
I COUNTY CODE 14.08.42)
X Ip- ll-2�j
Signature of W ER Must si ned bv the OWNER Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
MASON COUNTY COMMUNITY SERVICES Permit No 2,0Z3 10
PERMIT ASSISTANCE CENTER: RECEIVED
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
Y.;
615 W.Alder Street,Shelton,WA 98584
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone �O^^
Beltair.(360)275-4467•Phone Elma:(360)482-5269 OCT L3
BUILDING PERMIT APPLICATION 4 rZ 1,AV1. AlKierlareet
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMA
NAME: I NAME:
MAILIN DRESS: MAILING ADDRESS:
CITY: STATE: l ZIP: CITY: STATE: ZIP:
PHONE 41: PHONE: CELL:
PHONE#2: Zq9 E
EMAIL: 13=11MG# EXP.
PRIMARY CO�LJA'CT OWNER❑ CONTRACTOR❑ OTHER❑
NAME J Z)h Vl EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE • CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 2—� �+ '1 603 ZONING
LEGAL DESCRIPTION( bgre'vi`atFd) FIRE ISTRICT
SITEADDRESS �J-+ l U 15 L� UX4 / 1Q CITY $�
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑ SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Checkall Thai apply):
SALTWATER❑ LAKE❑ RIVER/CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
TYPE OF WORK: NEW❑ ADDITION❑ AL TION/i REPAIR❑ OTHER ❑
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Eic.)_ a r&x lL
IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES(Whole Bldg)❑ YES(Parrfs)oJBldg)❑ NO❑
DESCRIBE WORK
SQUARE FOOTAGE: (proposed)
1ST FLOOR sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK 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*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC❑ SEWER❑ / NEW❑ EXISTING❑
PLUMBING IN STRUCTURE? YES❑ NO❑ Ifyes,attach completed Water Adequacy Form
PERIMETERNOUNDATION 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.1 declare that I am the owner and 1 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 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
I COUNTY CODE 14.08.42)
X
ku2 nA. . ni" . -
Signature of W ER Must a si ned by the OWNER Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH