HomeMy WebLinkAboutBLD2006-00831 Coffee Stand - COM Permit / Conditions - 8/3/2006 (2) 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
RESIDENTIAL BUILDING PERMIT BLD2006-00831
OWNER: BRIAN PETERSEN
CONTRACTOR: LICENSE: EXP: RECEIVED: 5/18/2006
SITE ADDRESS: 13 NE OLD BELFAIR HWY BELFAIR ISSUED: 8/3/2006
PARCEL NUMBER: 123294200010 EXPIRES: 2/3/2007
LEGAL DESCRIPTION: TR 1 OF NW SE
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
Coffee Stand (8'6"x18') Corner of Old Belfair and Hwy 300.
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: Type of Constr.: VB
Type of Use: ? Insp.Area: No. of Bathrooms: Occ. Group: B Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 1 Occ. Load: 1 Building:153
Valuation: Building Height: Occ. Status: Prima Basement:
Manufactured Home Information Setback Information Shoreline& Planning Information
Make: Length: Ft. Front: Ft. Shoreline: Ft. Water Body:
SEPA?:
Rear: Ft. Slope: Ft.Model: Width: Ft. Side 1: Ft. Shoreline Desi g..
Year: Serial No.: Side 2: Ft. Comp. Plan Desig.:
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Kitchen Sink 1 Plan Check Fee KKK 5/18/2006 $81.41 S22006000
Planning Review Fee KKK 5/18/2006 $255.00 S22006000
NREC Fee DLC 6/12/2006 $58.00 612006000
Building State Fee DLC 6/12/2006 $4.50 612006000
Plumbing Fee DLC 6/12/2006 $7.00 812006000
Plumbing Base Fee DLC 6/12/2006 $20.00 612006000
EH Plan Review ADR 7/28/2006 $75.00 612006000
Building Permit Fee DLC 7/31/2006 $251.25 612006000
ADJUST—Plan Check Fee DLC 7/31/2006 $81.90 612006000
Total $834.06
BLD2006-00831 Please referto the following pages for conditions of this permit. 1 of 4
CASE NOTES FOR
BLD2006-00831
CONDITIONS FOR
BLD2006-00831
1) All construction must meet or exceed all local ordinances and the international codes requirements as adopted and amended by Mason County and the
f Wa hington. Occupancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would result in
er t ation.
2) A nges o "approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
rdi r regulation, must be reviewed and approved by Mason County prior to construction.
3) Any anges 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
th reto. If d cuments are removed, approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour) will be
d shall be collected by the Building Department prior to any further inspections being performed or approvals granted.
4) CO RUCTION 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 . ternat' nal codes as amended and adopted by Mason County. Any corrections, changes or alterations required by a Mason County Building
I Fngpermits
made prior to requesting additional inspections.
5) All b shall have a final inspection performed and approved by the Mason County Building Department prior to permit expiration. The failure
to rt
al inspection or to obtain approval will be documented in the legal property records on file with Mason County as being non-compliant with
Maordinances and building regulations.
6) MinBC rated fire extinguisher shall be installed inside the structure. The fire extinguisher shall be mounted not more than 48-inches above the
finishqrl4loor, measured to the top of the fire extinguisher.
X
BLD2006-00831 Please referto the following pages for conditions of this permit. 2 of 4
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 b cated wJ hin 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 proj t.
X
8) All permits expire 1 a after permit issuance, or 180 days after the last inspection activity is performed. The Building Official may extend the time for
actin for a pe . d not exceeding 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the permit
h revented action from being taken. No more than one extension may be granted.
X
9) All ;PWans 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 t p (or to any further inspections being performed or approvals granted.
10) In acc rd e with international codes and Title 14, Mason County Building Code, "Standards for Fire Apparatus Access Roads," all new structures that
require address shall have approved numbers or addresses located at the beginning of long driveways when the address is not clearly visible from the
access road. The numbers shall also be plainly visible and legible from the street or road fronting the property and shall contrast with their background.
Mason County Building Department requires that this be completed prior to calling for any site inspections. A re-inspection fee based on rates as adopted
by the jurisdiction and the international codes will be assessed if the owner and/or contractor fail to post the address on site prior to requesting
inspe� i
X
11) All prop�ert es shall be clearly identified at the time of foundation inspection. X
12) Contractor registration laws are governed under RCW 18.27 and enforced by the WA State Dept of Labor and Industries, Contractor Compliance Division.
T20
ial risks and monetary liabilities to the homeowner for using an unregistered contractor. Further information can be obtained at
The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
13) ECTION R905 - REQUIREMENTS FOR ROOF COVERINGS - R905.1 Roof covering application. Roof coverings shall be applied in
it
the applicable provisions of this section and the manufacturer's installation instructions.
14) ECTION 1609 -WIND LOADS - 1609.1 Applications. Buildings, structures and parts thereof shall be designed to withstand the
nLirWnuw viad loads prescribed herein. Decreases in wind load shall not be made for the effect of shielding by other structures. Per FIGURE 1609
D SPEED (3-SECOND GUST) the wind speed for Mason County is 85 MPH.
X
15) tperdimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
X
BLD2006-0083 Please referto the following pages for conditions of this permit. 3 of 4
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
..ap oval 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
i D partment prior to any further inspections being performed or approvals granted.
17) An r o m accessible to persons with disabilities shall be available to staff and customers during operation. The restroom located in the the antique
stK[44 ck room is approved provided the door on the west end is aavailable.
X
18) This pafdel is located in a smoke management zone. Please contact a fire warden at (360) 427-9670 ext. 459 for further information.
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 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 inspectiop.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-and structure for reviewiand inspection.
OWN ER OR AGENT: _ DATE:
r}
BLD2006-00831 Please referto the following pages for conditions of this permit. 4 of 4
oI _U
CONCRETE MECHANICAL MANUFACTURED HOME
r� M
Date By
CD Footings i Setbacks Ribbons M
(71 Gas Piping X
(D Interior Date Bp interior-Date By Date P
CD U)
00 M
co Exterior Date By Exterior-Date By Set-up z
INSULATION
Point Load I Isolated Footings Date By
17"at P By BG I SLAB INSULATION
By FIRE DEPARTMENT >
Foundation Walls Floors Date F11 z
Date By Data By DECKS
FRAMING Walls 17 4,t1D 0, By AlZe Date
B 414e Data PROPANE TANKS
y
PLUMBING Vault :?v UAL
Date By A-5C OTHER
Groundviork Attic
Type
Uatc By Date By
Date Ly
D.W.V DRYWALL Type-
Int Brace Wall DateB,, 00
Da v
Dale By FINAL INSPECTION
Water Line Fire Separation
Date By Date By Date U
CD
Pass or Request Inspect. 6
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Type of Insp. Fail Date Date Done By Comments co
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6/2/06
Mason County Health Services
Attn: Amanda Reynolds
PO Box 1666
Shelton, WA 98584
Re: BLD2006—00831
Parcel #: 123294200010
Amanda,
Thank you for the note regarding our project. Unfortunately, I think I need to explain a
bit better than I previously have.
The proposed business going in at the corner of NE 11 Old Belfair Highway is already an
existing business "Michelle's Espresso" presently located in front of QFC in Belfair.
Since QFC is bringing Starbucks inside their store, Michelle's Espresso is forced to leave
this present location. Tania Punihaole and her employees are currently registered with
your office and have all of their food handling permits current.
The scenario will be the same in the new location as it presently is in the QFC location.
She is not presently hooked up to a septic system but has a self - contained 10 gallon
system which she dumps at maximum twice daily. This total ends up being 15 — 17
gallons per day.
The new location at NE I 1 Old Belfair Highway was previously Naomi's Florist shop
with significant water usage from Belfair Water. The present use is now an antique shop
with no employees but only the owner present throughout the day. I do not anticipate the
additional 15 — 17 gallons per day will affect the drainfield's present function. If you feel
this is a concern I would be willing to submit to a regular tank pumping schedule as
opposed to adding on to the septic system when the Belfair sewer installation is right
around the corner.
I hope this answers some questions or concerns for you. If you have any further
questions, please call me at 710 0855 or e-mail me at drbrianghctc.com at your earliest
convenience.
Sincerely,
Dr. Brian S. Petersen
ADIO 1, LLC
Latte Stand
NE 21 Old Belfair Hwy
• Water use is minimal as the stand has it's own contained system and utilizes only
20 gallons per day
• Bathroom use in adjoining tenant space (only one employee per shift—may or
may not utilize the bathroom
• Hot water for sanitation purposes is accessible with the self contained system and
with the adjoining tenant
• Parking is more than ample as the wearhouse/karate' space is only open after
3:00 p.m.
SR 300 X _
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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
RESIDENTIAL BUILDING PERMIT BLD2006-00831
OWNER: BRIAN PETERSEN RECEIVED: 5/18/2006
CONTRACTOR: LICENSE: EXP: ISSUED: 8/3/2006
SITE ADDRESS: 13 NE OLD BELFAIR HWY BELFAIR EXPIRES: 2/3/2007
PARCEL NUMBER: 123294200010
LEGAL DESCRIPTION: TR 1 OF NW SE
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
Coffee Stand (8'6"x18') Corner of Old Belfair and Hwy 300.
General Information Construction & Occupancy Information Square Footage Information
No. of Bedrooms: Type of Constr.: VB
Type of Use: ? Insp. Area: No. of Bathrooms: Occ. Group: B Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 1 Occ. Load: 1 Building:153
Valuation: Building Height: Occ. Status: Primary Basement:
Manufactured Home Information Setback Information Shoreline & Planning Information
Make: Length: Ft. Front: Ft. Shoreline: Ft. Water Body:
SEPA?:
Model: Width: Ft. Rear: Ft. Slope: Ft. Shoreline Desi
Side 1: Ft. g..
Year: Serial No.: Side 2: Ft. Comp. Plan Desig..
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty, Type Qty. Type By Date Amount Receipt
Kitchen Sink 1 Plan Check Fee KKK 5/18/2006 $81.41 S22006000
Planning Review Fee KKK 5/18/2006 S255.00 S22006000
NREC Fee DLC 6/12/2006 $5&00 B12006000
Building State Fee DLC 6/12/2006 $4.50 B12006000
Plumbing Fee DLC 6/12/2006 $7.00 612006000
Plumbing Base Fee DLC 6/12/2006 $20.00 B12006000
EH Plan Review ADR 7/28/2006 $75.00 B12006000
Building Permit Fee DLC 7/31/2006 $251 25 B12006000
ADJUST--Plan Check Fee DLC 7/31/2006 $81.90 612006000
Total $834.06
BLD2006-00831 Please referto the following pages for conditions of this permit 1 of 4
CASE NOTES FOR
BLD2006-00831
CONDITIONS FOR
BLD2006-00831
1) All construction must meet or exceed all local ordinances and the international codes requirements as adopted and amended by Mason County and the
f Wa hington. Occupancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would result in
er 't ation.
X
I
2) A nges o "approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
rdi r regulation, must be reviewed and approved by Mason County prior to construction.
3) Any Onges 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
th reto. If d cuments are removed, approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour) will be
d shall be collected by the Building Department prior to any further inspections being performed or approvals granted.
4) CO TRUCTION 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 ternat nal codes as amended and adopted by Mason County. Any corrections, changes or alterations required by a Mason County Building
I "ps e made prior to requesting additional inspections.
X
5) All b ng permits shall have a final inspection performed and approved by the Mason County Building Department prior to permit expiration. The failure
t r qu st 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
Ma ordinances and building regulations.
X
6) Minim A10BC rated fire extinguisher shall be installed inside the structure. The fire extinguisher shall be mounted not more than 48-inches above the
finish oor, measured to the top of the fire extinguisher.
X
3�
BLD2006-00831 Please refer to the following pages for conditions of this permit 2 of 4
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 b cated w hin 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 proj 11a
X
8) All permits expireafter permit issuance, or 180 days after the last inspection activity is performed. The Building Official may extend the time for
actin for a pe od not exceeding 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the permit
In re action from being taken. No more than one extension may be granted.
X
9) All app 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 t p 'or to any further inspections being performed or approvals granted.
10) In acc rd e with international codes and Title 14, Mason County Building Code, "Standards for Fire Apparatus Access Roads," all new structures that
require address shall have approved numbers or addresses located at the beginning of long driveways when the address is not clearly visible from the
access road. The numbers shall also be plainly visible and legible from the street or road fronting the property and shall contrast with their background.
Mason County Building Department requires that this be completed prior to calling for any site inspections. A re-inspection fee based on rates as adopted
by the jurisdiction and the international codes will be assessed if the owner and/or contractor fail to post the address on site prior to requesting
inspe i
X
11) All property es shall be clearly identified at the time of foundation inspection. X QV
12) Contractor registration laws are governed under RCW 18.27 and enforced by the WA State Dept of Labor and Industries, Contractor Compliance Division.
IThn kareotential risks and monetary liabilities to the homeowner for using an unregistered contractor. Further information can be obtained at
82. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
13) PerC - SECTION R905 - REQUIREMENTS FOR ROOF COVERINGS - R905.1 Roof covering application. Roof coverings shall be applied in
a nc ith the applicable provisions of this section and the manufacturer's installation instructions.
X
14) Per 2 0 RC - SECTION 1609 -WIND LOADS - 1609.1 Applications. Buildings, structures and parts thereof shall be designed to withstand the
M1rVMLdJ1 wi ad loads prescribed herein. Decreases in wind load shall not be made for the effect of shielding by other structures. Per FIGURE 1609
D SPEED (3-SECOND GUST) the wind speed for Mason County is 85 MPH.
X
15) A per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
X
BLD2006-0083 Please referto the following pages for conditions of this permit. 3 of 4
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
ap oval 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
i1so
epartment prior to any further inspections being performed or approvals granted.
17) An r m accessible to persons with disabilities shall be available to staff and customers during operation. The restroom located in the the antique
StQ,jAack room is approved provided the door on the west end is aavailable.
X
18) Thi located in a smoke management zone. Please contact a fire warden at (360) 427-9670 ext. 459 for further information.
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 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 pro s inspectio . he gent on the owners behalf, represents that the information provided is accurate and grants employees of Mason County access to
the above described p ope tru a or review and i pection.
OWNER OR AGENT: DATE:
BLD2006-00831 Please refer to the following pages for conditions of this permit. 4 of 4
MASON COUNTY ,
DEPARTMENT OF HEALTH SERVICES
& rf
4
s
PO BOX 1666 Shelton WA 98584
Shelton (360) 427-9670
Fax (360) 427-8442
BRIAN PETERSON Elma (360) 482-5269
PO BOX 370
BELFAIR WA 98528 Belfair (360) 275-4467
Case No.: BLD2006-00831 Parcel No.: 123294200010
Dear Applicant:
Your building permit cannot be approved by Mason County Environmental Health until
the following are completed and turned in:
Please call me at (360)427-9670, ext. 279 if you have any questions.
Sincerely,
Amanda Reynolds
Environmental Health
Mason County Health Services
Comments: There is no explination of where you will be disposing of the waste from
the coffee stand. If you plan to dispose of the waste in the existing
drainfield, you will need a designer to address the increase in flows and
waste strength. Where are you getting the water? This must be from
an approved source. You also need to apply for a food permit. I have
attached an application.
1 of 1 BLD2006-00831
FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO
-W
PLEASE PRESS HARD BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 C) ?� j
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269 V 1
On the web www.co.mason.wa.us
APPLICANT JJN FORMATION CONTRACTOR INFORMATI N
Owner g/ S Company Name o0tt VC d
Mailing Address -70 Mailing Address
City Statel_0A Zip Code City State Zip Code
Phone 7— 72-7 Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address :::lr- bC-i�s�v. cam}' kc'f'c . �r E Mail Address
Drivers Lic. #P1=I�+eBS�Z3j`�R DOB T 8 Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Sep E istin Se is
Connect to Water System Name of Water System
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Di it ParceIN . Z 3— — — Q<nnjoO Fire District
Legal Description SS
Site Address (Please include street name, street number and city) LD
Directions to site '�Z�ct r_.R rt:IE A- ER o
Will timber be cut and sold in parcel preparation?Yes
Is property within 200' of Saltwater NQ Lake _Ngo River/Creek A/o Pond NO
Wetland_4jCL_Season aI Runoff &D Stream ND Slopes or Bluffs �/o
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye
TYPE OF JOB - New_,C Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building 44. e& -5 escribe Work
No. of Bedrooms No. of Bathrooms Square Footage- 1st Floor J/yy 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INF MATION - Make Model Year
Length Widt erial No. No. of Bedroo No. of Bathrooms
Type of Heat Purchase Pri Repla ent Unit? Yes/ No
Installer Na 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 1 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. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if tr ion work is spended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANS OFAPROGRES§INSPECT IN TIVITYOF HI ERMIT APPLICATION OF 180 DAYS ILL INVALI ATE THE APPLICATION.
X cat
Date:
ner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: L Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department �� V-) b -11 w
Planning Department
Environmental Health Department G
Fire Marshal 1Z
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood /Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
a4yo
Mason County Permit Assistance Center
Planning Intake Checklist
Owners Name: Date:
Project: 1U Reviewed By:
Commercial Develop Twlrk— _ NO Comments:
Planner: GBM TS �MM KJM PBC RDH
Site :
North Arrow
Q�-'Property Dimensions: `�7 X C
Streets and Driveways Shown.Road name:
❑ All Existing Structures shown with setbacks
-0 Well Location, Septic and Drain-field Shown with setbacks
�a Identify all surface water(streams,ponds, shoreline,wetlands, etc.) ►� �`�'
43 Topography(slopes)
❑ Proposed Structure Setbacks (Dlrec on/Setback):
F: / S1: IJ / S2: L /
o- Utility and Drainage Easements: Yes ? °O jif yes enter condition#5022)
-a- Other Easements )\J / I�
_1a- Accessory Appurtenances L
-❑ County Access Permit Needed(add condition#0010) f
.$ State Access Permit Needed(add condition#0020)
Standard Conditions to be added to all Building permits that planning reviews:#5019 and#0700
Are there any impediment that may restrict access to your site? (dogs/gates)
N\ � -
Shoreline and Planning Info
Setbacks: Shoreline: Slope:
Shoreline Designation: Comprehensive Plan: Rural Zoning:
❑ Not Applicable ❑ Agricultural ❑ RR 2.5 5 10 20
❑ Urban ❑ In-holding ❑ RMF
❑ Rural ❑ LTCFL ❑ RC 1 2 3
❑ Conservancy ❑ Rural ❑ RIl r Wik
❑ Natural ❑ RAC ❑ RNR
❑ Unknown ❑ RCC-Han-let- ❑ RT
an.Growth Ar ❑ MPR
❑ U owns ❑ Unknown
Water Body(type of water if unnamed):
SEPA: Yes No U own
Flood Plain: YES NO U4 wn Map#
Aquifer Recharge: YES NO L�aiown Map#
Tags/Cases: -
RLC/SPI Case:, Y 6-Year Dev. Moratorium: YES O,
Eagle Nest Tag: YES O Other YES
Addressing: Check box if needed ❑ Reviewed by: �
Revised:11-01-2005 1:\PLANNING\PAC\PLANNING INTAKE
MASON COUNTY PERMIT NO
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584 , QO g �D>
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICANT FORMATION CONTRACTOR INFORMATION
Owner .Zr � / T .SSvc/ Company Name
Mailing Address Mailing Address
City L-F#4 r'2 State f 1 Zip Code S City State Zip Code
Phone — s 2z? -Other Ph. l/d 6g-,; Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address jr �� d-ti. h c 'f c • ?'A E Mail Address
Drivers Lic. #P j' QS3Z3ryrr2 DOB Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System E Ad , (,t f (t
Well Sewer System Name of Sewer System
PARCEL INFORMATION - 12 Di it Parcel No. 2 — — — O Fire District 2—
Legal Description S�
Site Address (Please include street name, street number and city) L D £L C-<' �
Directions to site «
1" .1
Will timber be cut and sold in parcel preparation?Yes A/p Pond Nd
Is property within 200'of Saltwater NQ Lake Z725 River/Creek
Wetland 4A4 Seasonal RunoffAAD—Stream_-, Slopes or Bluffs > 15% A. r,/0 is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New__XAdd Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building s4a IaDescribe Work
No. of Bedrooms No. of Bathrooms, Square Footage- 1st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length WidtlL__�Serial No. No. of Bedroo No. of Bathrooms
Type of Heat ---'" Purchase Pri Repla, ent 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. This permit/application becomes null & void if work or authorized construction is
not commenced within 180 days or if corik;tryetion work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEANSOFAPROGRES INSPECTII,CY.IN CTIVITYOFTlH ERMIT APPLICATION OF180DAYS ILL INVALIDATE THEAPPLICATION.
X c /. G , Date:
ner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by:_. 11 Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department D6 116,40CC49 "-CI C- i 1l k%Z-)`1 f I" t[ i Tlt
Plannin De artment t �"`�l,'1Su1�,'�� ,l '
Environmental Health Department
Fire Marshal 1
FEES _
Building Permit Fee, asl-a5
Site Inspection P °
Plan Review EH Review Fee
Plumbing& Base Fee Planning Review Fee
Mechanical & Base fee Other t' re
Wood /Gas/ Pellet Stove Fee State Fee
Violation Fee S Pre-Paid at Submittal ��• ��
Valuation$ X T6 �5 0 TOTAL FEES