HomeMy WebLinkAboutBLD2008-01377 Final MFG Home Used as ADU - BLD Permit / Conditions - 5/22/2009 Inspection Line 262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427(96700,ext7352
Mason County Bldg. III 426 W. Cedar P.O. Box 186
Shelton,WA 98584
1�
RESIDENTIAL BUILDING PERMIT
BLD2008-01377
OWNER: WENDELL MOORE
CONTRACTOR: HUNT MOBILE HOMES 360-373-5001 LICENSE: GORSTLD0981-1 EXP: 6/7/2010 RECEIVED: 11/12/2008
SITE ADDRESS: 75 NE FERN WY BELFAIR ISSUED: 3/19/2009
PARCEL NUMBER: 123292290020 EXPIRES: 9/19/2009
LEGAL DESCRIPTION: NW NW NW NW TR C OF SP#249 AF#318795
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW MANUFACTURED HOME approved as an accessory living quarter 2 MILES WEST ON NORHT SHORE RD FROM BELFAIR, TURN RIGHT ON
under case#D D R2008-0021 0. SANDHILL RD .9 MILES TO BALL PARKS TURN RIGHT TURN LEFT 1ST
ROAD AT BERRY BEST PRESCHOOL SIGN
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: 2 Type of Constr.:
Type of Use: MH Insp.Area: No.of Bathrooms: 2 Occ. Group: Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 1 Occ. Load: Building:
Valuation: Building Height: Occ. Status: Basement:
Manufactured Home Information Setback Information Shoreline&Planning Information
Make:Fleetwood Length: 28 Ft. Front: E 48.0 Ft. Shoreline: Ft. Water Body: NONE
Rear: W 240.0 Ft. Slope: Ft. SEPA?: No
Model: Width: 40 Ft. Shoreline Desig.: Not Side 1: N 50.0 Ft. Applicable
Year:2009 Serial No.: Side 2: S 220.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Mobile Home Submittal Fee KS 11/12/200 $247.00 S12008000
Planning Review Fee KS 11/12/200 $190.00 S12008000
Water Adequacy Plan Review KS 11/12/200 $40.00 S12008000
EH Plan Review KS 11/12/200 $40.00 S12008000
Address Fee KS 11/12/200 $162.00 S12008000
Fire Warden Review KS 11/12/200 $68.00 S12008000
Mobile Home Issuance Fee MAL 11/17/200 $247.00 61200900o
EH Plan Review CEW 2/12/2009 $63.00 612009000
EH Plan Review CEW 3/6/2009 $63.00 612009000
Additional Plan Check Fee RTB 3/11/2009 $36.50 612009000
Total $1,156.50
BLD2008-01377 Please referto the following pages for conditions of this permit. 1 of 5
CASE NOTES FOR a.
BLD2008-01377 ,
CONDITIONS FOR +
BLD2008-01377
1) 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.
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2) The international code requires a fire apparatus access road for every facility, building, or portion of a building that is more than 150' from an approved
access road. Roads are required to meet the minimum Mason County Fire Marshal standards for Fire Apparatus Access Roads up to the point where
such roads connect with a county maintained public road or to another fire apparatus access road which connects to a county maintained public road.
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3) All approved plans are required to be on-site for inspection purposes. If an inspection is called for and plans are not available on site, then approval will
not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and must be collected by the Building
X eparlttmgr prior to any further inspections being performed or approvals granted.
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4) Owner Age , 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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5) The plan review check list and corrections are part of the approved plans and must remain thereto. It is the responsibility of the applicant to make the
corrections indicated on the plans. Once the plans are marked "APPROVED", they shall not be changed or altered without authorization from the Building
Official. The permit holder is responsible to retain the complete approved set of plans on site for the duration of the project. Failure to comply and/or
removal of approved documents will result in failure of required building inspections.
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6) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X IJ.n
7) The"approved" site plan is required to be on-site for inspection purposes. If an inspection is requested and the"approved" site plan is not on site, then
approval will not be granted. In addition, a re-inspection fee (refer to current fee schedule, minimum 1 hour)will be charged and shall be collected by the
Buildin Department prior to any further inspections being performed or approvals granted.
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BLD2008-01377 Please referto the following pages for conditions of this permit.
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8) Any retailer, manufacturer or contractor who installs a manufactured home warrants that the manufactured home is installed in accordance with the State
Installation code, chapter 296-150M WAC. All installers hired to do installation work shall be certified manufactured home installers and shall be present ;
to supervise the installation of all on-site work. An Installer Tag shall be posted on site giving the certification number and signature of the certified
installer responsible for each major part of the installation. RCW43-63B.090 P
An approved Installer cerification tag shall be placed on the end of the manufactured home directly above or below the HUD certification tag or temporarily
located in plain site within three of the home's front entry. There shall be one certification tag for each certified installer accounting for the work that each
installer performed or installed. certification number and signature of the certified installer responsible for each major part of the installation.
WAC365-210 X 6,n ,
9) If you are installing a manufacturing home and no longer have the installation manual for the home, you must use the instructions of the American
National Standards Institute (ANSI). To order the ANSI instructions you may either get an order form from the Mason County Building Department or you
can co�t c the Offfice of Manufacturing Housing (360) 725-2800.
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10) Per 2003 IRC - SECTION 1609-WIND LOADS - 1609.1 Applications. Buildings, structures and parts thereof shall be designed to withstand the
minimum wind loads prescribed herein. Decreases in wind load shall not be made for the effect of shielding by other structures. Per FIGURE 1609
BASIC WIND SPEED (3-SECOND GUST) the wind speed for Mason County is 85 MPH.
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11) Per IRC - SECTION R905 - REQUIREMENTS FOR ROOF COVERINGS - R905.1 Roof covering application. Roof coverings shall be applied in
accordance with the applicable provisions of this section and the manufacturer's installation instructions.
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12) A Mason County Stormwater Management Worksheet was completed and signed as part of this building permit application. Design, sizing, placement,
inspection and maintenance of stormwater management systems shall be the responsibility of the owner/agent of the developed parcel. It is the
owner/agent/contractor's responsibility to ensure that Mason County Department of Public Works has approved the stormwater site plan for this parcel
prior to the commencement of any development activities. "NOTE if Stormwater Management option "A"was selected on the Small Parcel Stormwater
Management Application/Worksheet the document entitled "Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan" constitutes
an approved plan based on the criteria listed on the application/worksheet. If the development has, or will have, a septic/drainfield system you are
responsible for contacting 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. By calling for a final inspection of
the building permit the owner/agent/contractor's acknowledging that all components of the stormwater management system have been installed as
approved on the stormwater site plan. X 6
13) All construction must meet or exceed all local ordinances and the international codes requirements as adopted and amended by Mason County and the
State of Washington. Occupancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would result in
permit revo afion.
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14) Lake Cushman area is designated with a 551b snow load rating. The owner/agent of this permit acknowledges that if the unit permitted under this permit
does not me t the recommended snow load rating, there is a potential for failure due to weight accumulation beyond that of the design criteria.
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BLD2008-01377 Please referto the following pages for conditions of this permit. 3 of 5
15) REQUIRED INSPECTIONS (Footing Inspection-prior to pour, Set-up Inspection-prior to skirting, Final Inspection-prior to occupancy). I hereby assume all
responsibility for the scheduling of my required inspections. If the required inspections are not requested, inspected and signed off(approved) by the
inspector in the prescribed order, I understand that reinspection fees and an hourly investigation fee pursuant to the current fees adopted by the Mason
County Building Dept., and will be assessed in addition to my original permit fees to resolve any questionable practices or problems that have beerl '
discovered. I further understand that this investigation will be scheduled as time allows. Until resolution of any/all problems no occupancy (Final
Inspection)will be granted for the residence.
OWNER/CONTRACTOR(indicate which) Signature X
16) This permit is for the placement and installation of the manufactured home only and does not imply approval or review for any other items indidcated on
the plot plan. X P.,r).
17) 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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18) Placeme t of structure must comply with standards set forth per the international codes regarding descending and/or ascending slopes.
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19) All changes to"approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance Qregulation, must be reviewed and approved by Mason County prior to construction.
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20) 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
IInspecto shall be made prior to requesting additional inspections.
21) The installation permit shall be displayed in clear view of the site access road. The approved site plan and other applicable instructions, including
installation instructions, shall be available in this location OR placed in the location specified by WAC 296-150M-655. Support configuration shall be
clearly marked in the installation instructions.
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22) All property lines shall be clearly identified at the time of foundation inspection. Xj
23) All building permits shall have a final inspection performed and approved by the Mason County Building Department prior to permit expiration. The failure
to request a final inspection or to obtain approval will be documented in the legal property records on file with Mason County as being non-compliant with
Mason County ordinances and building regulations.
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BLD2008-01377 Please referto the following pages for conditions of this permit. 4 of 5
24) All permits expire 180 days after permit issuance, or 180 days after the last inspection activity is performed. The Building Official may extend the time for
action for a period not exceeding 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the permit
holder ve prevented action from being taken. No more than one extension may be granted.
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25) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners, -
connect
nn ctQr and flashing. Install metal connectors approved for contact with the new types of pressure treated material.
26) Prior to final approval, all upland areas disturbed or newly created by construction activities shall be seeded, vegetated or given an equivalent type of
erosion protection (silt fencing or straw matting).
27) Landings and stairs must meet the same setback conditions as any permitted structure; and, must be shown on your site plan. Please check your
"AppNe4$ite Plan"to ensure these structures are shown and meet the setback conditions listed.
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28) By definition, propane tanks and heatpumps are structures, which must meet setback conditions. Please check your"Approved Site Plan"to ensure
these structures meet the setback conditions listed.
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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 inspection.The owner or the agent on the owners behalf,represents that the information provided is accurate and grants employees of Mason County access to
the above described property and structure for re 'ew and inspection.
OWNER O GE , C DATE:
BLD2008-01377 Please referto the following pages for conditions of this permit. 5 of 5
o CONCRETE MECHANICAL MANUFACTURED HOME 0
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o Date By O
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Footings I Setbacks Gas Piping A Ribbons
o Interior Date By Interior-Date y • 4 Y`C'By Date �j •�j d B rn
4 Exterior Date By Exterior-Date B Set-up m
Point Load/Isolated Footings INSULATION Date B T, Z
BG 1 SLAB INSULATION
Date By Data By FIRE DEPARTMENT m
Foundation Walls Floors Date By r
Date By Data By DECKS
FRAMING Walls Date By
Date By Data By PROPANETANKS
PLUMBING Vault Date By
Date By OTHER
Groundwork Attic
Date By Date By Type:
Date By
D.W.v DRYWALL Type_
Int.Brace Wall Date By W
Date By Date By FINAL INSPECTION 0
`D Water Line Fire Separation C
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� Date By Dale By Date .S� 2- l '�� BY//( O
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Pass or Request Inspect.
Type of Insp. Fail Date Date Done gy Comments w
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s Name���—L�� Parcel#1232922010020 LD#
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Department of Communi Develo Wien
Small Parcel Stormwater Management Application/Worksheet (page 1 0f*
Per Mason County Code, Title 14, Chapter 14.48 a stormwater site plan is required whenever a building application is
made for residential development, or redevelopment', with more than 2,000 square feet of impervious surface 2.
'Redevelopment means,on an already developed site,the creation or addition of impervious surfaces,structural development
including construction, installation or expansion of a building or other structure,and/or replacement of impervious surface that is not
part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment.
2Common impervious surfaces include,but are not limited to, rooftops,walkways,patios,driveways,parking lots or storage areas,
concrete or asphalt paving,gravel roads,packed earthen materials, and oiled,macadam or other surfaces which similarly impede the
natural infiltration of stormwater. Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
To Calculate Impervious Surfaces Please Complete This Table
Surface Type Length X Width = Area All dimensions in feet
Buildings X =
9LIK u6s x 40 X D = 2 Measurements for buildings are taken at the
pa,.fesc AQu 23 X 46 perimeter of the farthest projections(example.-
eaves/gutters)
t 6 X
Driveways X =
Y-EL : 3M X - 10 = 3 Length of drive begins at the right of way
L o4a ma X =
Parking Areas X =
IOCA-A&U& X = Any paved, gravel or packed area per definition
X _ above table
Patios/Walks X =
IMCLu! U/ X = Any paved, gravel or packed area per definition
above table
X =
Others X =
X = If the total impervious area of the proposed site
X = development is greater than 2000 square feet a
Small Parcel Stormwater Site Plan is Required
Total Impervious Surface Area (sum of all areas)
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01�,X-y 11 ai IS 14W t o-eew �
If the Total Impervious Surface Area is LESS THAN 2000 Square Feet, please read,acknowledge and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below. 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 Area is GREATER THAN 2000 Square Feet, please read,acknowledge and sign
the information provided on page 2 of 2.
Page 1 of 2
Name * Parcel# BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 2 of 2)
Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity.
Title 14, Chapter 14.48 of the Mason County Code(MCC) regulates compliance requirements for Stormwater
Management in this jurisdiction. A complete copy of the ordinance can be found on the Mason County website:
httpHwww.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"
INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE
A) he relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
irety AND the system will be located as not to adversely affect any septic systems on this, or any other,parcel.
4��An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the
system will be located as not to adversely affect any septic systems on this,or any other,parcel.
If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works
Department can provide additional instructions, guidance and examples. (Section 14.48.130)contact Public works at:
Phone: (360)-427-9670 EXT. 450
Mail: P 0 Box 1850, Shelton WA 98584
Physical: 415 N 6th St, Shelton WA 98584
If this development has,or will have,a septic/drainfield system you may need to contact Mason County Division of
Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or
any other, parcel. You may also wish to consult with the septic design professional involved with the project. Mason
County Division of Environmental Health can be reached at:
Phone: (360)-427-9670 EXT. 352
Mail: P 0 Box 1666, Shelton WA 98584
Physical: 426 W Cedar St, Shelton WA 98584
A condition will be added to the building permit that states, in part, that all conditions the stormwater site plan will be met
prior to a request for final inspection of the building permit.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
AcknowI d ent of such is by signature below. I declare that I am the owner, owner's legal representative,or the contractor. I
further ack o edge that the information provided is accurate and employees of Mason County are granted access to the above-
described ro rty for review and inspection as may be required. Q
X Own /A e Contractor(circle one)Date: �� O
Page 2 of 2
Wendell Moore
NE 73 Fern Way
Belfair,WA 98528
360-275-5567
Mason County Department of Community Development
P.O.Box 186
Shelton,WA 98584
RE: Small Parcel Stormwater Management
To Whom It May Concern:
This application is subject to a pending special use permit for the installation of a new 28'x40' Fleetwood
manufactured home to be used as an ADU. This proposal adds only 1120sq ft of new impervious surface;
however,this home is replacing a previous unit that burned several years ago which was approximately
980sq ft. The net effect is that we are adding approximately 140sq ft of new impervious surface from the
prior ADU.
Under the calculations for stormwater management,the prior total(with original ADU)impervious surface
was 6300sq ft. The new calculations are 6440sq ft,of which only 1120 are new.
The primary residence is not being changed or amended in anyway and has its own functioning
roof/driveway stormwater management.
We would respectfully request that we be allowed to splashblock this new manufactured home. The
installation site is essentially level with good drainage and no evidence of standing water either historically
or at the present time.
Thank you for your consideration of this request.
i t regards,
7 S ncer,
fo n II D. Moore
PZoN.STgTFO� MASON COUNTY
o DEPARTMENT OF COMMUNITY DEVELOPMENT
4 MO
o N Planning Division
7 N y ti P O Box 279, Shelton, WA 98584
0° �0
1864 (360)427-9670
REQUEST FOR ADDITIONAL INFORMATION
November 19, 2008
WENDELL MOORE
P.O. BOX 783
BELFAIR WA 98528
Parcel No.: 123292290020
Project Description: ADU - install new manufactured home.
Dear Applicant:
You have submitted a permit application (case no. DDR2008-00210) for proposed
construction or development in the county. Upon review of your application, I require
additional information to complete the permit review process.
Therefore, review of your application will not proceed until the necessary information
is provided (see the comment section of this letter for details.) Once the information.
is submitted and the application is complete, I will continue to process your
application accordingly. If the additional information is not provided to the County
within 180 days of this request, the application shall expire and no further action on
the proposed development shall take place.
Please contact me at (360) 427-9670, ext. 360 if you have questions.
Sincerely,
Grace Miller
Land Use Planner
Mason County Planning Department
11/19/2008 Page 1 of 2 DDR2008-00210
REQUEST FOR ADDITIONAL INFORMATION
11/19/2008 Case No.: DDR2008-00210
Comments: It appears there are two issues that need to be resolved before I can
process your Special Use Permit Application for an accessory dwelling
unit.
1) The application which you have submitted is for a 1,120 square foot
manufactured home. The maximum living space area allowed for
accessory dwelling units is 1,000 square feet. This amount applies to
all heated areas. Is it possible that the utility room is not heated and is
120 square feet or more in size?
If the heated "living area" is over 1000 square feet in size, a
Development Regulations Variance would be required. Hopefully the
variance is not necessary. It will be necessary to revise your application
to reflect that the living area does not exceed the maximum 1,000
square feet.
2) It appears the accessory dwelling unit is over 150' from the primary
residence. This too would require a Variance from the attached
standards. Please revise your site plan to reflect this requirement.
Y� If you have-an questions, lease let me know. Thank you.
Y have-any p
coo
yak Pease let me know at your earliest convenience. Thank you.
1z���ag .flu tv4k,.- Ati "AA&a a,hc. ,t
11/19/2008 Page 2 of 2 DDR2008-00210
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APPROVED
MASON GCU `-- � DCD PLANNING
SITE PLAN REO'.!: TO BE ON SITE
cf CHANGES SUBJECT TO APPROVAL
By _ ,� /�•� Date 4j-Oj—
NEW
MASON COUNTY PERMIT No=> �/�.d'
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 '40e" Company Name µVS 060\65
Mailing Address 3 Mailing Address
City �" State Zip Code CityE¢•TtiN State Zip Code
Phone R $� Other Ph. Phone34om Il l Other Ph.
Lien/Title Holder Contractor Reg.#66(25f 130961•\ Exp.
E mail address E Mail Address
Drivers Lic. # DOB Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System-2 PnQyy On". PE011146
Well Sewer System Name of Sewer System
PARCEL INFORMATION -12 Di it P rcel q Z 29z. Fire District
Legal Description NLti vw m W`�N ( 9
Site Address (Please include street name, street number and city;) veo.N V
Directions to site NO R • ( wo �'u- L
Will timber be cut and sold in parcel preparation?Yes
Is property within 200' of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs 0%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building RN Describe Work
No. of Bedrooms 7o' No. of Bathrooms 72" Square Footage- 1 st Floor 11 2nd Floor
3rd Floor Basement Deck— Covered Deck Other Sq. ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED TOME INFORMATION - Make F164TW Model Year'
09
LengthZA__WidtH!±QL Serial No. 'SO No. of Bedrooms --I?" No. of Bathrooms
Type of Heat A- Purchase Price$ 5®. Replacement Uni
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
describ property and structure for review and inspection. This permit/application becomes null & void if work or authorized construction is
not co ced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
MEAN ESS INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILLINVALIDATE THE APPLICATION.
is
X Date: I
w / ers 13ep e/Contractor (indicate which one)
FOR O ICIAL USE BEYOND THIS POINT Accepted by � Date
DEPARTMENTAL REVIEW APPROV D DENIED NOTES
Building Department
Planning Department
Environmental Health Department Sit
Fire Marshal
FEES
Building Per Fe Site Inspection
Plan Review e 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