HomeMy WebLinkAboutCOM2007-00130 Final Cell Tower Addition - COM Permit / Conditions - 3/11/2009 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262
' Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone. (360)427-9670,ext.352
Shelton,WA 98584
rfrl COMMERCIAL BUILDING PERMIT COM2007-00130
OWNER: VERIZON WIRELESS RECEIVED: 11/30/200-1
CONTRACTOR: LICENSE: EXP: ISSUED: 1/25/2008
SITE ADDRESS: 24765 NE STATE ROUTE 3 BELFAIR EXPIRES: 7/25/2008
PARCEL NUMBER: 123282190030
LEGAL DESCRIPTION: TR 3 OF NE NW* LOT: C OF SP#745
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
Cell Tower Addition. SR 3 to address.
General Information Construction &Occupancy Information
Type of Use: Insp.Area:
No. of Units: Type of Constr.:
of Bathrooms: Occ. Group:No.
Type of Work: ADD Fire Dist.:Valuation: $ 13,665.00 No. of Stories: Occ. Load:
Building Height:
Pre-Manufactured Unit Information Square Footage Information
Make: Length: Lot Size:
Model: Width: Building: :
Year: Serial No.: Basement: Parking Spaces:
Setback Information
Shoreline&Planning Information
Front: Ft. Shoreline: Ft.
Rear: Ft. Slope: Ft. Water Body: Shoreline Desig.:
Side 1: Ft. SEPA?: Comp.Plan Desig.:
Side 2: Ft.
Fire Protection System Information
Auto Fire Alarm System?: Emergency Key Box?: Standpipe?:
Auto Fire Sprinkler System?: Access Road?: Fire Extinguishers?:
Fixed Fire Suppression System?: Fire Hydrants?: Fire Lanes?:
COM2007-00130 Please refer to the following pages for conditions of this permit. 1 of 5
Plumbing Fixtures Mechanical Fixtures FEES
` Type Qty. Type Qty. Type By Date Amount Receipt
Plan Check Fee KKK 1113n/9nn R917 Q1 S99nn7nn
Building State Fee ni r. 1/17/9nnR U sn g99nnAnn
Building Permit Fee ni r. 1/17nnnR 1.017 95 C,?9nnRnn
Total $459.66
CASE NOTES FOR
COM2007-00130
CONDITIONS FOR
COM2007-00130
1) Owner/Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title
14.28.
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2) ALL CONSTRUCTION MUST MEET OR EXCEED ALL LOCAL CODES AND THE INTERNATIONAL CODE REQUIREMENTS AND
OCCUPANCY IS LIMITED TO THE PERMITTED AND APPROVED CLASSIFICATION. ANY CHANGE OF USE OR OCCUPANCY WOULD
RESULT IN PERMIT REVOCATION. CHANGE OF USE MUST BE APPROVED PRIOR TO CHANGE. x <-j=}"T
3) Changes to approved building plans that affect compliance to the current Washington State Energy Code (WSEC), ventilation and Indoor Air
Quality Code (VIAQ), Building/Plumbing/Mechanical Codes and/or Mason County Regulations shall be approved prior to construction.
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4) Any changes in construction shall be reviewed by engineer of record and submitted in writing to the Mason County Building Department prior to
construction. All engineering documents are a part of the approved set of plans and must remain attached thereto. If engineering documents are
removed, approval will not be granted. In addition, a reinspection fee, based on the current fee schedule, minimum one-hour will be charged and
collected by the Mason County Building Department prior to any further inspections being performed or approvals granted.
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5) 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 Inspector shall be made prior to requesting additional inspections.
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6) 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-comPlli^@nt with Mason County ordinances and building regulations.
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COM2007-00130 2 of 5
7) PER TITLE 14 MASON COUNTY BUILDING CODE-CHAPTER 14.17, STANDARDS FOR FIRE APPARATUS ACCESS ROADS - 14.17.110.-
A fire apparatus access road in excess of 14% grade and more than 150'to new residential or commercial structures will require an automatic fire
sprinkler system installed. Contact the Mason County Fire Marshal at(360)427-9670, extension 273, for further information.
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8) 49(onpole structure was constructed under building permit BLD93-01836. A final inspection was never performed or approved by Mason
. An inspection performed by the engineer of record for this project, or their authorized representative, will be performed to verify existing
gondition co form with construction documents and conditions of analysis.
G �� D UU fnsn re ort shall be submitted t
�,�p p p o the Mason County Building Dept. prior to the final inspection, Attn. to D Coker, Mason County Building
�'I 186, Shelton, WA 98584. The inspection report shall also be avaialbe for inspection.
9) Provisions for surface/subsurface drainage control must be implemented with new construction or development on site and MUST NOT adversely
impact adjacent parcels. Under the requirements of Mason County Stormwater Ordinance, either private ditches and drains will meet requirements
of the stormwater ordinance or prior approval will be granted to use an existing utility and drainage easement dedicated for that specific purpose.
For further information regarding this ordinance and the REQUIREMENT to obtain an ACCESS PERMIT for the installation/construction of a
driveway or access connecting from a Mason County Road, Contact the Mason County Public Works Department prior to construction at Ext 450.
For any construction which is proposed to be located within 25' of a Mason County road right of way, it is suggested to contact that office to review
future planned work which may affect your project.
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10) 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
Xthe permit holder have prevented action from being taken. No more than one extension may be granted.
11) All approved plans are required to be on-site for inspection purposes. If inspection is called for and plans are not on site, Approval WILL NOT be
granted. In addition, a reinspection fee, based on the current fee schedule, minimum one-hour will be charged and collected by the Mason County
Building Department prior to any further inspections being performed or approvals granted. X =)-r
12) All property lines shall be clearly identified at the time of foundation inspection. X
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 1-800-647-0982. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to
WA state law. X <;(_
14) Approved per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
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15) The approved site plan is required to be on-site for inspection purposes. If inspection is called for and the site plan is not on site, Approval WILL
NOT be granted. In addition, a reinspection fee, based on the current fee schedule, minimum one-hour will be charged and collected by the Mason
County Building Department prior to any further inspections being performed or approvals granted.
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16) Recyclable materials &Solid Waste Storage: Space shall be provided for the storage of recycled materials and solid waste. The storage area
shall be designed to meet the needs of the occupancy, efficiency of pick-up, and shall be available to occupants and
haulers.X-3A
COM2007-00130 3 of 5
17) International Buildig Code CHAPTER 17: IN ADDITION TO THE INSPECTION REQUIRED IN IBC, SECTION 109, THE OWNER OR THE
ENGINEER OR ARCHITECT OF RECORD ACTING AS THE OWNER'S AGENT SHALL EMPLOY ONE OR MORE SPECIAL INSPECTORS
WHO SHALL PROVIDE INSPECTIONS DURING CONSTRUCTION ON THE TYPES OF WORK LISTED UNDER CHAPTER 17. THE SPECIAL
INSPECTORS DUTIES & RESPONSIBILITIES SHALL BE AS SPECIFIED IN CHAPTER 17.
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18) A structural observation, as defined in Chapter 17 of the International Code, shall be provided by the engineer or architect of record responsible for
the structural design or another engineer or architect designated by the engineer or architect or record.
Prior to the final inspection of the structure the structural observer shall submit written statements to the Mason County Building Department
indicating that the site visits have been made and identify any reported deficiencies.
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This permit becomes null and void if work orconstruction authorized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at any time after work is
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 inspe 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 prop stru ure for review and inspec'on.
OWNER OR AGENT: A DATE:Q l 1?-1 -0 E
COM2007-00130 4 of 5
1'(raZ;an & ASSOCIATES , INC .
GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING
CONSTRUCTION TESTING & INSPECTION
February 14,2008 KA Project No.: 106-08024
Wren Construction
Rod Crawford
2720 Oakes Ave.
Everett,WA 98201
RE: WA4 Cell Tower
Dear Mr.Crawford:
In accordance with your request and authorization,the following test data are presented on the following reports,
which are enclosed:
February 8 Field Report No.92037
Referenced concrete reports and compressive strength data will be mailed following 28-day tests,if applicable.
If you have any questions,or if we can be of further assistance,please do not hesitate to contact our office.
Respectfully submitted,
oc�C�
Penn Seely,Laboratory Manager
Peninsula Division
PS:pm
Enclosures
Client-email
With Offices Serving The Western United States
20714 State Hwy.305 NE, Suite 3C•Poulsbo,Washington 98370•(360)598-2126•Fax:(360)598-2127
aZafl & ASSOCIATES,INC.
GEOTECHNICAL ENGINEERING • ENVIRONbIENTAL ENGINEERING FIELDT�
CONSTRUCTION TESTING &. INSPECTION REPORT J.�r
NO.:92037
NATURAL RESOURCESIWETLANDS
_DATE: February 8 2008 CONTRACTOR:Wren Construction
PROJECT* 106-08024 PERMIT NO.: BLDG93-01836
PROJECT: WA4 Belfair INSPECTOR: John Kupferschmid
LOCATION: Belfair, WA JURISDICTION: Mason County
KRAZAN PROJECT MANAGER: JMB WEATHER: Cloudy TEMP:45'
Krazan &Associates on site for structural steel/bolting inspection of previously erected cell
tower (150' monopole). Met with two Wren Construction employees at 7:45am, results of
inspection are as follows:
1_ Foundation found to be an 84" corrugated metal pipe filled with concrete. Foundation
cap is projects from 3" to 6" above finish grade.
2. Sixteen 2 Y2" anchor bolts were found. Anchor bolt circle is 50", base plate is 58" in
diameter and is 2 V thick. Approximately 8" of grout is under the base plate and weep
holes were provided. Twelve inches of threaded projection on anchor bolts, above top
of concrete foundation observed.
3. Four monopole sections observed (40', 40', 40' and 30', bottom to top). Sections are as
follows:
A_ Bottom section of monopole (40'height) is 42" in diameter at the top and bottom
of section. Material thickness is 0.94" at the top and bottom.
B. Second monopole section from bottom (40' to 80' height) is 36" in diameter at
the top and bottom of section. Material thickness is 0.79" at the bottom and
0.78" at the top.
C. Third monopole section from the bottom (80' to 120' height) is 30" in diameter at
the top and bottom of section. Material thickness is 0.53" at the bottom and
0.54" at the top.
D. Fourth (last) monopole section, from bottom (120' to 150' height), is 24" in
diameter at the top and bottom of section. Material thickness is 0.35" at the top
and bottom_
4. Monopole section connections are as follows:
A. Connection at 40' height: 1 '/2" splice plates 42" outside diameter x 36" inside
diameter. 42 each Y4"diameter by 4 Y2" length, grade A325 bolts present.
6 bolt holes found absent of bolts.
B. Connection at 80' height: 1 V splice plates 36" outside diameter x 30" inside
diameter. 35 each 3/" x 4 '/2"A325 bolts present, with one bolt hole absent a
bolt.
C. Connection at 120' height: 1 '/2" splice plates 30" outside diameter x 24" inside
diameter. 30 each 5/8" diameter by 4 '/2"A325 bolts present.
KA No. 106-08024
FR 92037
Page No. 2
5. Verified snug tight condition of 10% of bolts at each monopole connection using a 24" x
'/2" drive torque wrench set to maximum value. All nuts are locking wire type nuts.
Additional findings : 1. No microwave dish installed at 75'.
2. Marker light installed at 100'.
3. 1 1/2" electrical conduit for warning light.
4. Four%2" diameter stainless steel bolts at cap plate (1/16" thick).
5. Antenna arms mounted to monopole by 13/16" plate bolted (four
3/4" x 3 '/"A325 bolts) to W plate (tapered at ends) welded to
monopole.
To my best of knowledge, expect for the 7 missing bolts noted in 4A and 4B the above WAS/WAS
NOTI performed in accordance with the approved plans, specifications, and regulatory requirements.
Superintendent/Representative: Inspector: John. , ' fersch�rlid
215 West Dakota Ave.,Clovis,CA 93612 (559)348-2200 226 N.Sherman,Ste.A,Corona CA 92880 (909)549-1188
4231 Foster Ave.,Bakersfield,CA 93308 (661)633-2200 1501 15"St.NW 11106,Auburn,WA 98002 (253)939-2500
1025 Lone Palm Ave.,Ste.2E,Modesto,CA 95351 (209)572-2200 20714 SR Hwy.305,Ste.3C,Poulsbo,WA 98370 (360)598-2126
545 Parrott St.,San Jose,CA 9581 t2 (408)271-2200 19501 144"Ave.NE kF300,Woodinville,WA 98072 (425)485-5519
123 Commerce Circle,Sacramento,CA 95815 (916)564-2200 11913 NE 103`d Ave.,Vancouver,WA 98662 (360)254-3200
E—Yazan& Associates, Inc.
Offices Serving'Me Western United States
Kri
- & ASSOCIATES , INC .
GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING
CONSTRUCTION TESTING & INSPECTION
February 14,2008 Project No.: 106-08024
Mason County
Mark Core—PAC Manager
P.O.Box 186
Shelton,WA 98584
RE: Final Letter Regarding Special Testing& Inspection Permit No.:BLDG93-01836
WA4 Cell Tower/Belfair,WA
Dear Mr.Core:
In accordance with our client's request and authorization, we have performed special testing and inspection
services for the above referenced project.The special inspections for this project were:
Special Inspection Required Performed
Structural Steel:
Welding ❑ ❑
�. Bolting
Sprayed Fire Resistive Materials ❑ ❑
Reinforced Concrete ❑ ❑
Pre-Stressed Concrete ❑ ❑
Shotcrete ❑ ❑
Structural Masonry ❑ ❑
Soils:
Site conditions ❑ ❑
Fill placement/compaction ❑ ❑
Load bearing ❑ ❑
Engineered Retaining Walls ❑ ❑
Temporary Erosion and Sediment Control ❑ 0
Pile Foundations ❑ ❑
Pier Foundations ❑ ❑
Expansion/Epoxy Anchor Bolts ❑ ❑
Lateral Framing ❑ ❑
Seismic Resistive Systems:
HVAC ❑ ❑
Piping and Mechanical ❑ ❑
Electrical ❑ ❑
Exterior Wall Panels ❑ ❑
Suspended Ceilings ❑ ❑
Access Floors ❑ ❑
Steel Storage Racks ❑ ❑
Fabrication Shop Inspections:
With Offices Serving The Western United States
20714 State Hwy. 305 N E Ste. 3C•Poulsbo,Washington 98370•(360)598-2126 9 Fax: (360)598-2127
Y -
1
& ASSOCIATES , INC .
GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING
CONSTRUCTION TESTING & INSPECTION
February 14,2008 Project No.: 106-08024
RE: Final Letter Regarding Special Testing&Inspection Permit No.:BLDG93-01836
WA4 Cell TowerBelfair,WA
To the best of our knowledge, all work and noted deficiencies have been tested and/or inspected and have been
found to be in accordance with the approved plans and specifications.
If you have any questions or if we can be of further assistance, please do not hesitate to contact our office at
(360)598-2126.
Respectfully submitted,
KRAZAN&ASSOCIATES,INC.
Jeff y M.Bowers
Construction Services Manager
Poulsbo Division
JMB/sgw
cc Wren Construction —Rod Crawford
I
With Offices Serving The Western United States
20714 State Hwy.305 N E Ste. 3C•Poulsbo,Washington 98370•(360)59&2126•Fax: (360)598-2127
NVREN
Construction
1410 80" St SW
Suite A
Everett,WA 98203
Telephone: (425) 252-1282
Fax: (425) 252-2860
wren con stru cWDaol.com
February 20,2008
VERIZON WA4 BELFAIR TOWER SUMMARY
• Base of tower is grouted per plan with weep holes (5 5/8" grout thickness)
• 16 x 2 %" anchor bolts with 12" projection out of the tower foundation
• Base plate is 2 %11 thick and a 15'-2 %:" circumference
• There is a 7' culvert in place at the top of the tower foundation sticking up 4"
above the gravel base
• Section 1: 30' long,24"diameter, 6'-4" circumference, .35 thickness, (30)5/8
A-325 bolts at section 1-2
• Section 2: 40' long,30"diameter, 7'-11" circumference, .53 thickness, (35)3/4
A-325 bolts at section 2-3 (1) bolt missing
• Section 3 & 4: One piece instead of two,40' long,36"diameter, 9'-6"
circumference, .79 thickness, (42) (Only 42 holes not 48 per drawing)'/4 A-325
bolts at section 4-5
• Section 5: 40' long,42" diameter, IV circumference, .94 thickness
• Obstruction light kit at 1001,Beacon light on top of the tower
• There is a 1 %2" ridgid conduit running full length on the exterior of the tower
for the lights
• Two entry ports at base of pole per plan
• Exit ports are 6" diameter pipe sleeves @ 391,721,79' 118' and 147'
• There is not a MW Dish at 75'
• There are (3) 5' stand-off arms at the top of the tower bolted with 5/8
hardware to welded flanges on the tower
• One stand-off has an azimuth of 50 degrees and is empty
• Two stand-offs have azimuths of 170 and 290 degrees with (2)20' x 4" OMNI
antennas installed, one up and one down each arm
• There is a 2 3/8 x 6' antenna pipe attached to the end of the stand-off arm,
the attachment is with a pair of 3 %z OD x 2 3/8 OD pipe adapter kits with 5/8
U-bolts for hardware
• The OMNI antennas are attached to the antenna pipe by a pair of large
DB370s using 5/8 hardware
• Please see attached photos
• Please see the Krazan Field Report and Final Summary Letter
T/t a5ed
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LEGEND OWNER NAME:
SHARON 0 BROSE
EXISRAG III LINE PARCEL ID: 123213490050
EXIS NG AOACEM PROPERTY LINE
LINE
__—_—EXISTING(EASE AREA
EXISTING EASEMENT ABUILOMGT
EXISTING WOOD FENCE
EXISTING WARE FENCE AMERICAP4 TOWER*
EXISTING AC7AL FENCE OWNER MAME
EX/STAG GUARD RAIL STACY, WTLLAM R IR 11 TRUDY N ATC TOWER SERVICES,LLC
EXISTING CNWNLINK FENCE PARCEL ID: 12J213490070 3600 REGENCY PARHWAY
EXISTING ROAD(DIRT) BUTTE 100
C
EXISTING ROAD(STONE)
EXISTNG ROAD(PAYED) 1 S PHONNE:E:CO((A NC 46 K.4t-0112
A:W.
NOTES'
1. BOUNDARY LINES OBTAINED FROM MASON �-
COUNTY ONLINE dS. PARCEL ro: 123219999999
2. ZONING INFORMATION OBTAINED FROM 1 I1
ZONING ORDINANCE. 1 i
PRODICONN
LEGAL DESCRIPTION:TR C OF SIP(745 AF 10 VIA A SOLUTIONS,INC
LAMEDA
#373646 EX N 30-MASON CO CT CASE �1i- (�
Bu/LDINC REDONDO BEACH-CA 90277
ry SE6-1 PTN of SW OF SECT 21 Bu/L� TEL:424240.9751
R NWW O OF F SEC 28
W OWNIAMER NAME: SPAY REV. DESCRIPTION BY DATE
Q ST PARCEL
ID.' 12J2/J490020Y N p-10' PRELIM VT om7m
� BC u„ ,.,�. QO 1 Wl1 CONSTRlICT10N VT 01/1722.
w cn
�� OWNER NAME
BELFAIR MINI STORAGE,LLC ---
0 PARCEL ID: 123282190040
— A A OWNER NAME ATC SITE NUMBER:
VJ BELFAIR MINI STORAGE, LLC
Ltd PARCEL ID: 123282 1 9 00JO 410875
WO OWNER NAME: ATC SITE NAME
U BELFAIR MIN/STORAGE. LLC WA4BELFAIR WA
PARCEL ID: 123282 1 9 00 1 0 BUiLDINCT
w T-MOBILE SITE NAME
BUR. BE :
Q LFAIR RELO-ATC
SITE ADDRESS:
OWNER NAME.' 24M NE SR3
ICY, WTLLAM M-&TRUDY N BELFAIR.NN 98528be20
BUiLDINGT PARCEL ID: 12J2621WO20
SEAL. �R
_ N
OND
Eg
BUILVINCT �OJ z
RAL
�870NAL
01/21/2022
OWNER NAME TMobfle
HARBOR CUSTOM DEVELOPMENT
PARCEL ID: 123282100000 DATE DRAWN: 07r 1
ATC JOB NO: 1354.T927 D3
CUSTOMER ID: BELFAIR RELOATC
CUSTOMER#.. SE06146A
1 OVERALL SITE PLAN
OVERALL SITE PLAN
GRAPHIC SCALE N
sa a n So
SHEET NUMBER: RENSION'.
(N FEET I 0-001
W S 0
1 T- FEET
9NINNVId
n
O
o CONCRETE MECHANICAL MANUFACTURED HOME _ m
p Footings !Setbacks Date By N
Ribbons Gas Piping O
po Intenor Date By ►nterior-Date By Date By Z
wp Gxtergr Date By Exterior-Date By Setup
-- -
Point Load!Isolated Footings INSULATION Date By m
BG 1 SLAB INSULATION r
Date By Data t3y FIRE DEPARTMENT m
Foundation Walls Floors Date By to
N
Date By Data _ By DECKS
FRAMING Walls Date By
Date By Data By PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attic
Type:
Date By Date By Date By
o.w.v DRYWALL Type n
Int.Brace Wall Date By 0
Date By .„__ _ E
Date By FINAL INSPECTION c
Water Line Fire Separation �—� O
Date By Date By Date3 -C� By r v
O
O
Pass or Request Inspect.
Type of Insp. Fail Date Date Done By Comments o
a G�
U1
0
U1
.� 6_7
MASON COUNTY PERMIT NO. EEO I ��
BUILDING PERMIT APPLICATION
426 W.Cedar•P.O.Box 186,Shelton,WA 98584
Shelton (360)427-9670• Belfair(360)275-4467•Elma (360)482-5269
_ On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner Veriron\h/irele ss(I essee)Akent:RealConi-Sarali'I'elscho%,, Company Name 11)13
Mailin Address . 14,632 SE East t ate Way, Suite 260 Mailing Address
City ffellevue _State WA7in Cride 98007 City State 7ipSo e
Phone(425)27444,4 cxt. t t4 Othpr h. Phone Other Ph.
Lien/Title Holder � Contractor Reg.# Fxp.
E mail address _stelsi�hoNv@realcorriassoc.coni E Mail Address
Drivers Lic.# N/A DOB N/A Drivers Lic.# DOB
SEPTIC/WATERISY51'EM INFORMATION - Connect to New Septic N/A Exisring Septic N/A
Connect to Water System Name of Water System N/A
Well water System Name of Water System
PARCEL INFORMATIC IN - 12 Digit Parcel No. 3
Legal Description Se, Sheet A-2 of the plans
Site Address(Please include street name,street number and city) 24763 NE State Route 3
Directions to site See Sheet T-1 of the plans
Will timber be cut and sold in parcel preparation?Yes/ o
Is property withir 200'of Saltwater lake River/Creek Pond
Wetland „iusonal Runoff Stream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add X Alt Repair Other PRIMARY.RESIDENCE[I SEASONAL ❑
Use of Building Telecom Describe Work See enc o�gject Description
No.of Bedrooms IN A Nn of Bathrooms NIA Square Footage-1st Floor N/A end Floor N/A
3rd Floor Basement N/A nPrk Covered neck N/A Ot N/A Sq.ft. N/A
Garage ,a�1._An ached N/A Detached Carport N/A Attached N/A Detached N A
MANUFACTURED HOME INFORMATION - Make N/A Model Year N/A
Length-W,-Ith serial No. N/A Nn of RPdrnoms No N/A of Bathrooms N/A
Type of Heat _._A_P_urthase Price$ N/A Replacement Unit? Yes/No
Installer Name N/A CPrtifiratinn No. N/A
CANNER/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 1 am the owner,owners legal representative,or the contractor.I further declare th at I am entitled to receive this
permit and to do the work 3s proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other parry in interest regarding this application or the work proposed in the applica tion,I have obtained
permission om them to ap for this permit and conduct the work proposed.The owner or agent on owners behalf,represents t hat the information
provided is ccurate 3Dc gi ernployee"f-Ma County access to the above described property and structure for review and i nspection.
PROOF OF NTIN19 01�OF 0 IS BY MEANS 0 ROGRESS INSPECTION.
X � 1-r� I-o �-
/ i es to' / o or (indicate which one)
F04941CIAL USE 13EYOND THIS POINT Accepted by: `'Y Date I I I -
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department BILLG1 -
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee 37 Site Inspect on
Plan Review Fee U 1,54. EH Review Fee
Plumbing&Base Fee PlanningRe iew Fee
Mechanical&Base fee Other C6
Wood/Gas/Pell-=t Stave Fee State Fee
Violation Fe Pre-Paid at Submittal
Valuation � TOTAL FEE