HomeMy WebLinkAboutBLD2004-00688 Final SFR with Garage - BLD Permit / Conditions - 6/29/2005 Inspection Line(360)427-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427-9670,ext.352
Mason County Bldg. 3 426 W. Cedar P.O. Box 186
IP10 Shelton, WA 98584
RESIDENTIAL BUILDING PERMIT BLD2004-00688
OWNER: BRENT IRWIN RECEIVED: 5/10/2004
CONTRACTOR: HILINE HOMES 253-840-1849 LICENSE: HILINH*983BD EXP: 2/10/2006 ISSUED: 6/14/2004
SITE ADDRESS: 795 E GREENVIEW LN SHELTON EXPIRES: 12/14/2004
PARCEL NUMBER: 321352390001
LEGAL DESCRIPTION: E1/2 E1/2 SW NW EX LOT: 1 OF SP#2891 AF#647862
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
RESIDENCE WITH GARAGE HWY 3 NORTH TO MASON LAKE ROAD LEFT ON MASON LAKE RD RIGHT
ON MIKKELSEN RD RIGHT ON GRENVIEW LANE 3/4 MILE TO PROPERTY
ON LEFT
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: 3 Type of Constr.: V-N
Type of Use: SF Insp. Area: No. of Bathrooms: 2 Occ. Group: R-3/U-1 Lot Size: Deck:
Type of Work: NEW Fire Dist.: 3 No. of Stories: 1 Occ. Load: Building:2,112 Garage-Attached 528
Valuation: Building Height: 17 Occ. Status: Primary Basement: COV. PORCH 96
Manufactured Home Information Setback Information Shoreline & Planning Information
Make: Length: Ft. Front: S 314.0 Ft. Shoreline: Ft. Water Body: Cranberry creek
Rear: N 142.0 Ft. Slope: Ft. SEPA?: No
Model: Width: Ft. Side 1: W 72.0 Ft. Shoreline Desig.: Conservancy
Year: Serial No.: Side 2: E 193.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Dishwasher 1 Exhaust Hood 1 Plan Check Fee TW 5/10/2004 $838.86 S12004
Hoseblbs 2 Ventilation Fan 3 Planning Review Fee TW 5/10/2004 $155.00 S12004
Kitchen Sink 1 Dryer Vent 1 Building State Fee LDK 5/27/2004 $4.50 S12004
Lavatories 3 Building Permit Fee LDK 5/27/2004$1,301.75 S12004
Showers 2 Plumbing Base Fee LDK 5/27/2004 $20.00 S12004
Water Closets (Toilets) 2 Plumbing Fee LDK 5/27/2004 $96.00 S12004
Water Heaters 1 Mechanical Base Fee LDK 5/27/2004 $23.50 S12004
Bath Tubs 2 Mechanical Fee LDK 5/27/2004 $39.65 S12004
Clothes Washer 1 Adjust Plan Check Fee LDK 5/27/2004 -$578.51 S12004
EH Plan Review CEW 6/4/2004 $75.00 S12004
Public Works Review AT 6/7/2004 $39.22 S12004
Total $2,014.97
BLD2004-00688 Please refer to the following pages for conditions of this permit. 1 of 4
CASE NOTES FOR
BLD2004-00688
CONDITIONS FOR
BLD2004-00688
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�82 The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
X �J
2) The use, handling and storage of haz75�1
uTaterials or flammable and combustible liquids in excess of 10 gallons is not allowed without the approval of
the Mason County Fire Marshal. X
3) All upland areas disturbed or newly reed by construction activities shall be seeded, vegetated or given an equivalent type of erosion protection (silt
fencing or straw matting). X
4) Appro er Amensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
X ve
5) 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
Department for any further inspections being performed or approvals granted.
X i t
6) In accordance with the Uniform Building Code and Title 14, Mason County Building Code, "Standards for Fire Apparatus Access Roads,"all new
structures that require an 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 Uniform Building Code will be assessed if the owner and/or contractor fail to post the address on site prior to requesting
inspections.
X
7) The plan review check list and corrections, along with the Energy Compliance Worksheet (when applicable)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 cha ge or altered without authorization from the Building Official. The permit holder is responsible to retain the complete approved set of
plans on site nthe"tion of the project. Failure to comply and/or removal of approved documents will result in failure of required building inspections.
X
BLD2004-00688 Please referto the following pages for conditions of this permit. 2 of 4
8) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X
9) The"approved" plot plan is required to be on-site for inspection purposes. If an inspection is requested and the"approved" plot plan is not on site, then
approval will n 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
Building De p m t prior to any further inspections being performed or approvals granted.
X
10) Washington State Energy Code Compliance has been approved using the following:
Heat Type: Electric or other fuels Compliance Method: IV Window(Max U-Factor):0.40 Skylight (Max U-Factor):0.58
Doors (Type/Nl U1Factor):0.40 or less, Wall insulation R-21 , Floor insulation R-30 , Ceiling Insulation R-38, Vault Insulation R-30, Slab Insulation R-10
X � ]�
11) Owner/builder assumes all responsibility if drainfield/reserve area is encumbered. X
12) Stock Plan Identification number:
This project is approved subject to the provisions identified the Mason County Stock Plan Policy. The site/plot plan approved by the Planning Department,
original building plans, and all attachments approved by the Mason County Building Department shall be available for the Mason County Building
Inspector at ea h re fired inspection.
X
13) All construction must meet or exceed all local ordinances and the 1997 Uniform Building Code requirements as adopted and amended by Mason County
and the State of Washington. cc ancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would
result in permit revocation.
X
14) 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' a Mason County road right of way, it is suggested to contact that office to review future planned work which may
affect your project.
X r —4
15) All changes to"appro ed" bujilding plans that effect compliance with the Uniform Codes as amended and adopted, or any other Mason County ordinance
or regulation, m st evi ed and approved by Mason County prior to construction.
X
16) All property lines shall be clearly identified at the time of foundation inspection. X
BLD2004-00688 Please referto the following pages for conditions of this permit. 3 of 4
17) 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 inspec 'on or to obtain approval will be documented in the legal property records on file with Mason County as being non-compliant with
Mason County o anc and building regulations.
X
18) 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 excee 'ng 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the permit
holder have prevent ction om being taken. No more than one extension may be granted.
X
19) The approval of this project is subject to the recommendations and specifications outlined in th attached geotechnical report or assessment. Structures
and/or land modifications (grading, cuts, fills, etc.) required in the geotechnical repo ssess ent, may require a seperate permit. The geotechincal
report/assessment shall remain attached to the approved building plans. X
20) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
connectors, and flashin Install metal connectors approved for contact with the new types of pressure treated material.
X
21) All development of the site ' subject to the engineering geologist's recommendations within the geotechnical assessment prepared by David Strong and
dated 3/26/04.
X
22) Adequate erosion and sediment control features need to be implemented during land disturbing activities to protect neighboring properties and State
waters from adverse stormater runoff impacts. The migration or release of silty water or mud from the applicant's property will be considered a violation of
County and T!:—
at quality protection regulations.
X
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 owneror 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 f67 and i ection. J
OWN ER OR AGENT: DATE: v 1
BLD2004-00688 Please referto the following pages for conditions of this permit. 4 of 4
I�i
I C ON CREt E MECHANICAL MANUFACTURED HOME
Footings " etb c Date L 2, O-q B y (A) L- Ribbons
Date L7� j G By . Gas Piping Date B
Y
Foundation Walls Date B q Set-up
Date By INSULATION Date By
B G / Slab Insulation Floors Final
Date By Date )Z L } Date By
FRAMING Walls FIRE DEPT
Date 'Z , U4 Date 12 cJ/IL/ Date By
PLUMBING Attic OTHER
Groundwork Date By
Date By WALLPO RD N
D.W.V. Date h? 30 J<(
Date Z bH By L V- FINAL INS EC
Water Lined ) Date �[
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SON COUNTY DC!) PLANNING
SITE PLAN REQUIRE`) TO BE ON SITE
CHANGES SUBJECT TO APP,ZOVAL
j By ,�1M — D-.te _ a�
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APPROVED
MASON COUNTY DCD PLANNI"
SITE PLAN REQUIRED TO BE ON SIT -
j` CHANGES SUBJECT TO APPROVAL
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Plot Map Drawn To Meet
HiLine Homes Specifications.
Any Revisions To Be Made
By The Home Owner.
L
WORK ORDER - PUBLIC WORKS DEPT.
p4 Date: l ,I (E) Work Order
PERMIT M 2 y —C)C(,g� 6ve4 Number.
Requested by:
Authorized by: Date:
Type of Work:
CHARGE TO:
NAME
AGENCY/COMPANY
BILLING ADDRESS
PHONE
(B) Pub. Works Person In Charge:
(C) Project Time Line: (from-to dates) TO
Project Start dale: Estimated FiNsh Date:
Approximate hours: ESTIMATED TOTAL i'S:
COST ESTIMATE
(D) 2ft EnV4oyee t Rate Hours Subtotal Frtnae% TOTAL$
I um BALE TOTAL SS
EQUIPMENT USED:
MATERIAL USED:
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(F) Actual Cost $ BARS: PROD#:
DATE EmF4oyee
WORKED Naffs Flours Subtotal Frino% TOTAL$
EQUIPMENT USED: Date Ung Rate TOTAL
MATERIAL USED:
TOTAL ALL
(G) BILLED DATE INV 0 PAID DATE REC.X CKX
Case Activity Listing 9/8/2004
12:59:31PM`
Case#: BLD2004-00688
Assigoe_ Done
Activity Description Date 1 Date 2 Date 3 Hold Disp To By Updated Updated By
BLDC110 Footing Inspection 9/2/2004 9/3/2004 None COND RLS 9/7/2004 KLW
FOOTINGS PASSED,SETBACKS COND PASSED,ON BACK OF PERMIT COND#14 AND 22 INSTALL SILT FENCE.CONTACTING PLANNER OF AREA TO MAKE SITE VISIT TOOK CUT
AND PUSH/FILL AT SLOPE
Page 2 of 2 CaseActivity.apt
f 1
MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
WSEC/VIAQ Compliance Application
Owner t ( Telephonj�,,_q,2_Cq�4 Parcel#- OF
Type of project (�) New Residence ( ) Addition ( ) Remodel
Total Sq. Ft. 1 s Floor : 2 nd floor: Heated Basement:
of heated area:: ZII L- 2AU-
Heating System:
Glazing Prescri tive Option see reverse side circle one: 1 II III
Percentage: Compliance
Method O Component Performance , Chapter 5— Calculation worksheets required
'Z % Check one:: O Systems analysis, Chapter 4
Whole House Ventilation system O Whole House Ventilation using a Heat
Ventilation using exhaust fans&window or wall fresh air Recovery Ventilation System (VIAQ 303.4.4)
System vents (VIAQ 303.4.1)
Check one
O Whole House Ventilation Integrated O Whole House Ventilation using an inline
with a Forced Air System (VIAQ 303.4.2) supply fan. VIAQ 303.4.3)
Window & Door Schedule (If needed, attach an additional sheet)
Total
Manufacturer Room/location U-Factor Size Quantity Square Feet
Windows:
+
ALL- 5' 1 r �5
DE-ri (o'b x I 2
e1'oic3 l I
y'b xS�D / a0
2rdxsib l Ib
Windows: Total Sq. ft.
Doors: o�((e'Iv41
41
r
Doors: Total Sq. Ft $ Z
Total window and door area 2-4. 9 window &door area /(divided by) total sq. ft of heated area 2llZ = 1Z%of glazing
MASON COUNTY '
DEPARTMENT OF COMMUNITY DEVELOPMENT
Permit Assistance Center
SHELTO►v (360) 427-9670 BELFAIR (360)275-4467 SEATTLE (206)464-6968
ELMA(360)482-5269 FAx: (360) 427-7798 WEB SITE: www.co.mason.wa.us
P.O. Box 186, SHELTON 98584
2001 Washington State Energy Code (WSEC)
effective July 1, 2002
2000 Ventilation and Indoor Air Quality Code (VIAQ)
Code Compliance Application Form
The following information will be required for the WSEC and VIAQ plan review:
1. Complete the Washington State Energy Code/Ventilation and Indoor Air Quality Code
(WSECNIAQ)application located on the reverse side.
2. Complete the window and door schedule on the reverse side. Include all windows, skylights,
sliding glass doors, french doors and any door that is more than 50% glass. Use rough opening
dimensions of the windows and doors. Information about the U-factor of the window will also help
to expedite the energy code review. If you are complying with the WSEC by prescriptive path and
are using the area weighted average method you must include your calculations.
3. On your building plans note the location and fuel type of water heater, location of exhaust fans
(bathroom, laundry, kitchen, etc.) and R-factor of insulation proposed for walls, floors, ceilings and
slabs,
4. Questions? Call Mason County Community Development at (360) 427-9670 ext. 284. Additional
WSEC and VIAQ compliance information is available on the internet at:
www.energy.wsu.edu/buildings/
Prescriptive Requirements °,'for Group R Occupancy
Climate Zone 1, Table 6-1
Glazing Glazing U-factor Door Wall Wall Wall 4
Area%of Ceiling Vaulted Above interior4 exterior Slab
Option Floor „ U s 2 Ceiling3 Grade below 4 Below Floors on
10 Vertical Overhead Factor 12 grade Grade Grade
I 12% .35 .58 .20 R-38 R-30 R-15 R-15 R-10 R-30 R-10
II* 15%* .40 .58 .20 R-38 R-30 R-21 R-21 R-10 R-30 R-10
III Unlimited
Single
Family Res .40 .58 .20 R-38 R-30 R-21 R-21 R-10 R-30 R-10
(R-3)Only
*Reference Case/Call (360)427-9670 ext. 284 for footnote information. Log&solid timber wall with a min. avg.thickness of 3.5"are
exempt from the above grade wall insulation requirements.
Window Schedule
IHHiL INE for 2112 plan
O M E S
Manufacturer: Milgard Windows Inc. Model: Classic Series
Type: Vinyl U-Value = .36
Windows
Quantity Size/Handing Glazing area Total S . Ft. Location
width x heighth
1 5'0 x 5'0 25 25 Bedroom 2
1 5'0 x 5'0 25 25 Bedroom 3
1 6'0 x 4'0 24 24 Den
'1 6'0 x 4'0 24 24 Mstr. Bed
1 3'0 x 3'0 9 9 Mstr. Bath
1 4'0 x 3'6 14 14 Kitchen
11 4'0 x 5'0 20 20 Great Room
1 8'0 x 5'0 40 40 Great Room
1 2'0 x 5'0 10 10 Entry
Slid. Glass Doors
1 6'0 x 6'10" sgd 41 41 Dining
Total glazing area 232 sq. ft.
232 - 2112 = .109 X 100 = 11%
Glazing Area : Conditioned floor Area Glazing Percentage
If a sliding glass door option was chosen, switch the appropriate window w/the sliding glass door
and use the calculation below.
1 6'0 x 6'10" sgd 41 41 Appropriate Room
249 - 2112 = .117 X 100 = 12%
Glazing Area + Conditioned floor Area Glazing Percentage
All other doors,windows&skylights do not need to be calculated do to the fact they meet all minimum requirements.
MASON COUNTY PERMIT NO.:
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.
Shelton(360)27-9670/Beellf ir(360)275467'Elm,(360) 82-6269
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner9,,?bit (_ Bey)tr l � )I&u l J 1 t,111- Ipld)i r 1 Contractor Name alt-A 4-
Mailing Address 44ai Mailing Address } "'
City�Ok I State'aZip Code City Stater_ Zip Code^
Phone Other h. Ph.( - - )2� Other Ph.(���9�!O__, I�AAP_
Lien/Tit a Holder Contractor Reg. # Vah 41100�l P�L>
Address Expiration L
Wk
SEPTIC INFORMATION-Connect to New Septic ---,,Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No Fire District
Legal Description T1Z jpo?IA�'
Site Address(Please include street name,street number and city)-A�_ t7ft]T1.W 1 LJD,�,
Directions to siteAt
3 %
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek_Pond Wetland Seasonal Runoff Stream - -,
Slopes or Bluffs
TYPE OF JOB New Add Alt Repair Other Use of BuildingL:
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures IZ-1. tl k/ -a ( LPG Natural Gas Heatpump
Toilets 7 Tvoe of Unit No.of Units Fees
Bathroom Sink 3 Furnace —
Bath Tubs 2 Heatpumps —
Showers Z Spot Vent Fan Z
Water Heater I Propane Tank
Clothes Washer 1 Gas Outlets
Kitchen Sinks l Wood/Gas/Pellet Stove
Dishwasher ► Kitchen Exhaust Hood f
Hosebibs Dryer Vent I
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
appr val. first obtainintQ approval.
�( 1",A.( �11 Date t'1 l� k� X _.� — Date S zlolZJ
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
i
AEt'AftTNEENT.At REVIEW. APPROVED DIENIEU CONDITION CODES
Building Department
Occ Group Type Constr.
Planning Department
Other
Other
F£E3
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES
MASON COUNTY PERMIT NO. Z� �
BUILDING PERMIT APPLICATION �Qca
426 W. Cedar • PO. 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 bQ04T C 1PJUIt13 JA►jkk✓ S tA U*,C-19_W-t lCompany Name 1�1ut\1�c 1�fJ1\lF`�
Mailinci Addressq 3 Mailing Address
City —State _Zip Code City $tateliUil Zip CodeCllir
Phone Other Ph. Phoneme k� 25r3 LAI
�I� i�2.lDther Ph.
Li�fi/Title Holder - Contractor Re #C4i�PFe" rJrl�rw Exp.L.a 11F.,
mail add ress3AA 1 6�V—UAA W W-DAVAL TLM E MaiFWr_essU_1D&N1l� S �U�1�
Drivers Lic.# DOB D4ye4 _)V1111, �h��Y'c{ — DOB
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic_ Existing Septic
Connect to Water System Name of Water System
Welt Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal DescriptionTIR 1 of --.>P *gnu U BIDS'
Site Address (Please include street name, street number and city) *S IEW:5-r
Directions to site
1
Will timber be cut and sold in parcel preparation?Yes/(W~ S ( S '�
Is property within 200'of Saltwater Lake aver/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/ o
TYPE OF JOB - New Add Alt Repair Other PRIMARY RESIDENCE SEAS NAL ❑
Use of Building_ ►I -1.1(�. Describe Work j 1 -
No. of Bedrooms No.of Bathrooms Square Footage - 1 st Floo "f F oor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage 22t�k � -Mached - Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length Width nal No. No.of Bedrooms No. of Bathrooms
Type of Heat _ Purchase Price $ Replacement Unit? Yes/ No
Installer a 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 permis-
sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or the work propos i the;application I heave obtaine permission from t to apply for this permit and conduct the work proposed.
X
Vul CIA 11 '�V1 Date:� Z
caner Owners Repres tative/contractor (indicat which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department K-3 V-N �s 7 DL4 t� / fit'' 7 1
Planning Department
Environmental Health Department '".Zn(� l�
Public Works Department I N _
Fire Marshal UA-
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee PlanningReview Fee
Mechanical & Base fee Other
Wood/Gas/ Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES