HomeMy WebLinkAboutBLD2006-01810 Final SFR - BLD Permit / Conditions - 7/6/2007 Inspection Line(360)327-7262
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
i
RESIDENTIAL BUILDING PERMIT BLD2006-01810
OWNER: STEVE MUTEK
CONTRACTOR: LICENSE: EXP: RECEIVED: 10/6/2006
SITE ADDRESS: 597 NE TAHUYA RIVER RD TAHUYA ISSUED: 11/14/2006
PARCEL NUMBER: 322127590031 EXPIRES: 5/14/2007
LEGAL DESCRIPTION: TR 3-A OF SURVEY 1/138 NW1/4 LOT: 3 OF SP#628
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW SFR FROM BELFAIR ON NORTH SHORE RD, RIGHT ONTO BELFAIR-TAHUYA
RD, LEFT ONTO NE TAHUYA RIVER RD, SITE IS ON LEFT W/ BYS SIGN AT
ROAD & SITE.
General Information Construction &Occupancy Information Square Footage Information
No.of Bedrooms: 2 Type of Constr.: V-B
Type of Use: SF Insp.Area: No.of Bathrooms: 2 Occ. Group: R-3, U Lot Size: Deck:
Type of Work: NEW Fire Dist.: No.of Stories: 1 Occ. Load: Building:1,792 Garage-Attached 672
Valuation: Building Height: Occ. Status: Primary Basement: Cov. Porch 208
Manufactured Home Information Setback Information Shoreline&Planning Information
Make: Length: Ft. Front: S 145.0 Ft. Shoreline: Ft. Water Body: NONE
SEPA?: No
82
Side 1: W .0 Ft. pp
Model: Width: Ft. Rear: N .0 Ft. Slope: Ft. Shoreline Desig.: Not Applicable
Year: Serial No.: Side 2: E 610.0 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 KS 10/6/2006 $787.90 S12006000
Hosebibs 3 Furnace<100K 1 Planning Review Fee KS 10/6/2006 $155.00 s120060t)0
Kitchen Sink 1 Gas Outlets 2 Building Permit Fee JRN 10/11/200 $1,212.15 S22006000
Laundry Tray 1 Propane Tank 1 Building State Fee JRN 10/11/200 $4.50 s22006000
Lavatories 2 Ventilation Fan 3 Plumbing Base Fee JRN 10/11/200 $20.00 s22oos000
Showers 1 Heat Pump 1 Plumbing Fee JRN 10/11/200 $89.00 s22oos000
Water Closets (Toilets) 2 Dryer Vent 1 Mechanical Base Fee JRN 10/11/200 $23.50 s220t)t bbb
Water Heaters 1 Mechanical Fee JRN 10/11/200 $86.40 s22oos000
Bath Tubs 2 EH Plan Review AMH 11/9/2006 $75.00 s22006000
Clothes Washer 1 Total $2,453.45
BLD2006-01810 Please refer to the following pages for conditions of this permit. 1 of 4
CASE NOTES FOR
BLD2006-01810
CONDITIONS FOR
BLD2006-01810
1) 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 ads connect with a county maintained public road or to another fire apparatus access road which connects to a county maintained public road.
X
2) 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 prior to any further inspections being performed or approvals granted.
X
3) In accordance with international codes 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 international codes will be assessed if the owner and/or contractor fail to post the address on site prior to requesting
ins ons.
X
4) 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
remoygy of approved documents will result in failure of required building inspections.
X 4u
5) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X�
6) 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/Max U-Factor):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
BLD2006-01810 Please referto the following pages for conditions of this permit. 2 of 4
7) 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
BASI IND SPEED (3-SECOND GUST)the wind speed for Mason County is 85 MPH.
X
8) Per 2003 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.
X
9) Concrete used for basement walls,foundation walls, exterior walls, porches, carport slabs, steps exposed to the weather, garage floor slabs and other
vertical concrete work exposed to the weather shall have a minimum compressive strength of 3000 psi (IRC Table R402.2).M
X
10) 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 ocation.
X
11) 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 projecWh
^
X
12) All changes to"ap roved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance or re ion, must be reviewed and approved by Mason County prior to construction.
X
13) 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 b rior to requesting additional inspections.
X
14) All property lines shall be clearly identified at the time of foundation inspection. X
15) 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 Co ordinances and building regulations.
X
BLD2006-01810 Please refer to the following pages for conditions of this permit.
3 of 4
,16) —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
ho r have prevented action from being taken. No more than one extension may be granted.
X
17) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
conrActors, and flashing. Install metal connectors approved for contact with the new types of pressure treated material.
X
18) 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, 7-0982. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
X_T
19) Water quality is not to be degraded to the detriment of the aquatic environment as a result of this project.
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20) Prior to final approval, all upland areas disturbed or newly�rggated by construction activities shall be seeded, vegetated or given an equivalent type of
erosion protection (silt fencing or straw matting). X Q�`YY1
21) Appr per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
X
22) 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.
X Ln
23) Landings and stairs must meet the same setback conditions as any permitted structure; and, must be shown on your site plan. Please check your
AppWved Site Plan to ensure these structures are shown and meet the setback conditions listed.
X ���
V
24) OWNER MUST SHOW OOF OF WELL LOG AND SATISFACTORY WATER SAMPLE PRIOR TO TEMPORARY/PERMANENT OCCUPANCY OF
THE RESIDENCE. 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. Evidenc"f 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 rog 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 op rty nd structure or review and inspection.
OWNER RAGENT: DATE: pq
BLD2006-01810 Please refer to the following pages for conditions of this permit. 4 of 4
o CONCRETE MECHANICAL MANUFACTURED HOME
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tv Date 3 -2 By T/Z, ---
Footings /Setbacks Gas Piping Ribbons M
Interior Date By Interior-Date By Date x
c' Exterior Date B -C9 U)
o Y v Exterior Date f'J�� B TV 2, set-up --I
Point Load!Isolated Footings INSULATION Oatc By C
Date By BG J SLAB INSULATION Dale
Data By FIRE DEPARTMENT
Foundation Wails Floors Date By
Date By Data .7 �p 0�I BY6 T DECKS
FRAMING Walla Date_ By
Date -3-ZOtJ/> By j72, Data 3 Z Z Y"'7 By 7_/2 PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attic -7 k
Date By Date 16-1 g Y ! e0s: p�,
D.W.V �� , � DRYWALL/
Int.Brace Wall Date By
Dace .3-12- By j Date . BY 71
FINAL t S CTION
RL e' I Nv
Water Line Fire Sop*ration
Cn Date Date 3y Date By p
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Pass or Request Inspect. b
Type of Insp. Fail Date Date Dane By Comments Co
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PLANNING
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PRO�FR�41
CT�Ory OF TUR h�gSUR
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MASON COUNTY RESIDENTIAL PLANS SUBMITTAL CHECKLIST
Owner's Name: Date: (O -co - oy Reviewed By:
Documents
ilding Pemit Application Completed
anning Intake Checklist Completed,
to plan includes:Allowable building area,r f overhangs,decks,etc.
Fire Apparatus Access Road info required? Yes No
Energy Code Application Form-O Electric wall heater O Electric central furnace O LPG Furnace
*Heat pump with electric furnace O Heat pump with LPG furnace O Boiler(heat type )
/ O Other: Specify:
✓Mechanical/Plumbing Application-WATER HEATER FUEL TYPE eG
Engineering? Yes (Need 2 sets of calculations)No f✓ G chnical report or assessment? Yes No
Snow load: �S Seismic Zone(circle one): D1 r D2
Constructions ✓ 3 ►'lans.- COMPLETE SETS
Plans Legible _✓Recognized Scale Elevation Views _✓Cross Section
Fo ation Plan oof Framing Plan loor Plan—Use of rooms noted(all floor levels)
or Framing Plan-all floor levels represented? Loft, rspacteTc
awl
Deck Framing Plan,including covered.porch framing
Plan Details: q tl 2 -.1r
_Roof framing details,truss 1rwall
y be needed,truss or stick framed?
Wall Framing-Does bearinght exceed 10'?(En ine r' may be requi )
I lP � ' V
0n r j
Floor franung: Floor joists: � 1 }— "Floor beams: (_,Q X l a,
endow headers marked on plans: ypical header: CC X a T)
+' Foundation: footing size,reinforcement C, 7
Concrete Walls-Does Concrete Wall Height Excee . (Engineering may be required)
L,ea'ndings at all exits? Less than 30"above grade? Y /
Heated By Furnace-Location of Furnace A A Q
Fireplace/Stove Information Shown-Fuel Type? Location(s):
idow Sizes Marked on Plans
raced wall panels(shear walls rked on plans or lateral engineering? (Plans may not be approved if not provided.)
2-Story Garage? (Engineering may be required) R602.10.1, 1"story of a two-story D1-45%,D2—55%
COMMENTS:
ENGINEERING REQUIRED:
Braced wall panelsibraced wall lines are not marked on plans(R602.10)
Amount and location of bracing does not meet minimum required in Table R602.10.1
IRREGULAR BUILDINGS(Irregular Shape)R301.2.2.2.2
Irregular portions of structures shall be designed in accordance with accepted engineering practice. A portion of a building shall be
considered to be irregular when one or more of the following conditions occur:
1)Exterior braced wall line or BWP cantilevered or offset by more than 4'
2)Roof or floor is not laterally supported on all edges
2A)Portion of roof or floor extend more than 6 ft.beyond the braced wall line.
3)End of BWP extends more than 1 ft. over an opening more than 8 ft in width below.
4)Opening in a floor or roof exceed the lesser of 12 ft.or 50%of the least floor or roof dimension.
5)Portions of floor level are offset vertically
6) Shear wall lines do not occur in two perpendicular directions.
7)When a story above grade is includes masonry or concrete construction(exc: fireplaces,chimneys,and veneer).
When this applies the entire story shall be designed. In accordance with accepted engineering practice.
DESIGN CRITERIA: Wind 85 mph exp B(unless proven otherwise), Seismic Zone: , Snow: psf
2003 1RC Plans submittal checklist simplified/WORD
Mason County Planning Intake Checklist
Owners Name: _5-1-._1 iku mu he K Date: IO 6 -0(p
Project: - Reviewed By: nc
Commercial Developme S NO Comments:
PLANNER: GBM TSq CMM K7M PBC RDH
Sitp Plan:
a �V/ orth Arrow
,,Property Dimensions: "N 0 X ItA
treets and Driveways Shown. Road name: On n r
VII Existing Structures shown with setbacks 0 - F -huy�c�.*_rc� ed .
ell Location, Septic and Drain-field Shown with setbacl�
w Identify all surface water (streams, ponds, shoreline, wetlands, natural or historic drainage,
Refined drainage ditches)
ml Topography (slopes)-&)-ff"' a-c-e
Proposed Structure Setbacks (DirectionSetback): _
F: I�fj /�A_ R: a(r I I S1: e92- J S2: to its /
Utility and Drainage Easements: Yes �(if yes enter condition #5022)
m"�Other Easements
Accessory Appurtenances: Pro
ne / Heatpump
Variance applied for: Yes / - parking space allotted? es No L
tl(:It�QJ YVI�It..T
❑ 0628)
Standard Conditions to be added to all Building permits that planning reviews: #5019 and #0700
Site Access: Are there any impediments (dogs/gates) that my restrict access to your site?
/A
Is the site clearly marked? How? j Address YYI(,u►.P�¢.Ei }- �(cVR-
tv
14 Name mod- -huyc�- ��.d .
Critical Areas: ❑ Other: U
Setbacks: Shoreline: Slope:
Shoreline Designation: Comprehensive Plan: Rural Zoning:
❑ Not Applicable ❑ Agricultural X RR 2.5 D 10 20
❑ Urban ❑ In-holding ❑ RMF
❑ Rural ❑ LTCFL ❑ RC 1 2 3
❑ Conservancy ❑ Rural ❑ RI
❑ Natural ❑ RAC ❑ RNR
❑ Unknown ❑ RCC-Hamlet ❑ RT
❑ Urban Growth Area ❑ MPR
❑ Unknown ❑ Unknown
Water Body/OyRe of water if unnamed): r
SEPA: Yes No Unknown Flood Plain: YE NO Unknown Map#
Aquifer Recharge: YES/ O_)Unknown Map#
Tags/Cases:
RLC/SPI Case: zG4)i ,c�200_0 - 6-Year Dev. Moratorium: YE N
Eagle Nest Tag. YES/S Other YES O
Revised: 09-29-2006
77
MASON COUNTY PERMIT NOZ:��-
BUILDING PERMIT APPLICATION chuc 4.
426 W. Cedar- P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 - Belfair (360) 275-4467 - Elma (360) 482-5269 A\
On the web www.co.mason.wa.us
APPLIC INIF,,,ORMATIV CONTRACTOR INFORMATION
Owner
A -i . Company Name INFORMATION
1�ram
Maili Addre st q Mailing Address
A&.0-AL--&A- L- City State— Zip Code
City pl-mag-q -6 -State Zip Code h15
Phony41-A '377-t;W5: Other Ph. Phone Other Ph.
Lien/Title Holder No Contractor Reg. # Exp.
E mail address E Mail Address
Drivers Lic.# DOB 4L3d5q Drivers Lic.# DOB
SEPTIC I WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System V Name of Water System
Well Sewer System Name of Sewer System_
PARCEL INFORMATION - 12 Digit Parcel No. Fire istric
Legal DescriptionNt--. " LMwc: NW-*-M-46 :M aZk1jjfr I-AC t) Kit) 1VW OC4M
Al
Site Address (Plec in s et me, Vtgmbe d 6iry)TC0
A -F r)ir ns to s* YA 11 ly llkM6 �17&w ho��Zvv
A
A6 a ;fb&4�'44M/
r 7
Will timbIrle cut and sold in parcel, ara pre -6661 Yes
Is property within 200' of Saltwater Lake N t2 River Cre/k' -Pond
Wetland s ;>
SeasonalRunoff Stream--U�
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB.- New _Acicl_Alt_Repair O�thjr PRIMAIRY REbPENC 10 SEASONAL ❑
MW '00N
Use of Building Describe ork
No. of Bedroom�=No. of Bathroom ZSquare Footage- 1st i6o if 2-nd Floor NIX
3rd Floor ; —Basement—Deck—Covered Dec er —Sq. ft.
Gar ge-4n O�
'? Attached —Detached — Carport— Attached — Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length—Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit? Yes/ No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or
Acknowledgement of such is by signature below. I declare that I am the owner,owners legal representative, or the contractor-Wt4tlqe lare
that I am entitled to receive this permit and to do the work as proposed in the application. I declare that I have rd'btat tW t n from all
1 2 i jt�Zp
the necessary parties. If permission is required from any easement holder or any other party in interest regarding i all the work
proposed in the application, I have obtained permission from them to apply for this permit and conduct the sed. The owner or
agent on owners behalf, represents that the information provided is accurate and grants employees of Masu"o If4c tove
described property and structure for review and inspection. This permit/application becomes null & void if work or au hos"LVion is
not com enced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY
M FAPROGRESNPEC Op.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
Ij —/,o —/o
14 W Date:
X=ner/Owners Representative/Contractor (indicate which one)
caner
OFFICIAL USE BEYOND THIS POINT Accepted by: LP-- Date tp
DEPARTMENTAL REVIEW APPROYFD DENIED NOTES
Building Department_
Planning Department
Environmental Health Department !Sun
Fire Marshal =Wlz- - no
FEES A,41ftf Ito r�-
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbincl & Base Fee Planning Review Fee
Mechanical & Base fee i Other
Wood/Gas/ Pellet Stove Fee State Fee L 6
Violation Fee Pre-Paid at Submittal
Valuation $ TOTAL FEES
2
la
7f 7
PERMIT NO. 4
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar- P.O. Box 186, Shelton,WA 98584
Shelton (360) 427-9670 e Belfair(360) 275-4467- Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICAN I FO MATION CONTRACTOR 1NF,0RMATION
Owner ^ .-I A I - A-. '�� Company Name. C64 N*C
'
Mailin Addre q Mailing Address
"a
City tat UjAi�ipCocle qV149 City State— Zip Code
p— 40
Phone ..-Other Ph. Phone Other Ph.
Lien/
Title Holder Contractor Reg.4 Exp.
E mail address dCi E Mail Address
Drivers Lic.# DOB Ca 1 Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. Fire District
Legal Description NE!C0tAiQ/' W�_
Site Address (Please include Itreet name, street number and city) WiJI
Dire
.QW to site .4w rfv V.1A r
,�ire 4w'J�
-fur
Is property it in 200'of Saltwater _�J Pon
d-
Wetland r-1 Seasonal Runoff—N r" Stream 1'7*10 Slopes or Bluffs > 11561. tjQ
TYPE OF JOB - New--K, -Add —Alt — Repair Other Use of Building 9A ca.4
Location of Fixtures/Units - 1 st Floor 2nd Floor— Basement— Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric;_. _ LPC-L__ Natural Gas— Heat Pump
Toilets Type of Unit No. of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water HeaftI&I Propane Tank
Clothes Washer Gas Outlets
Kithen SinkV4 Wood/Gas/Pellet Stove
DishwasM 0 Kitchen Exhaust Hood
Hosebib I.-I Dryer Vent
Other 4 Other
Base Fee— tAf Base Fee
wit �
TOTAL PLUMBING— TOTAL MECHANICAL
OVVNERIBUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signoxe 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 a6y 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
providedi accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PR ONT UATIJ O WOR ll,'�,BY MEANS OF PROGRESS INSPECTION.
X! - — 64 .11 Date: 4q
Owners Aip6sentative/-Contractor (indicate 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
Occ Group—Type Constr. .
Planning Department
Environmental Health Department! FEES
Plumbing & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES