HomeMy WebLinkAboutGRD2012-00006 Repair Storm Damage - GRD Permit / Conditions - 9/20/2016 ► Inspecuutf Llne (30U)4L/-/LI�L
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427-9670, ext. 352
Mason County Bldg. 3 426 W. Cedar P.O. Box 279
Shelton, WA 98584
i�
LAND MODIFICATION BUILDING PERMIT GRD2012-00006
OWNER: LILLIWAUP GENERATING COMPANY RECEIVED: 4/20/2012
CONTRACTOR: LICENSE: EXP:
ENGINEER: LICENSE: EXP:
ISSUED: 7/3/2014 1
SITE ADDRESS: 601 N LILLIWAUP ST LILLIWAUP EXPIRES:
PARCEL NUMBER: 323192300000
LEGAL DESCRIPTION: LOT 2
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
Repair storm damage io hydroelectric facility on Lilliwaup Creek including US HWY 101 NORTH, L ON LILLIWAUP ST, FOLLOW TO THE END.
dredging 80 cubic yards of accumulated sediments near the intake box and NEED TO STOP AT HOUSE.
regrading the slope that slid in 2006 and took out the concrete box culvert
(used for conveyance of hydro water).
Inspection Area: Fill?: Yes
Comp. Plan Desig.: Rural Grading?: Yes
IRO Desig.: Cutting?: Yes
Shoreline Desig.: Urban Area Graded: 10,900.00 Square Feet
SEPA?: Yes Cubic Yards: 12,111.00
FEES
Type By Date Amount Receipt
Grading Plan Check Fee GMM 4/25/2012 $90.71 S120140001
Grading Permit Fee GMM 4/25/2012 $606.64 S120140001
Building State Fee GMM 4/25/2012 $4.50 S12014000i
Planning Review Fee GMM 4/25/2012 $205.00 S120140001
Planning Stormwater Rev GMM 4/25/2012 $255.00 S120120001
Building Plan Check Fee DLC 7/19/2012 $1,231.98 S120140001
Building Permit Fee DLC 7/19/2012 $1,895.35 S120140001
Total $4,289.18
GRD2012-00006 Please refer to the following page(s)for conditions of this permit. Page 1 of 5
(;UNUI I IUNS FUK
GRD2012-00006
1) Geotechnical Report
The approval of his project is subject to the recommendations and specifications outlined in the Geotechnical Report prepared by Jacobs Associates
dated Apr The report shall remain attached to the approved grading permit. All recommendations are to be considered required.
X
2) STORMWATER
The approval of this project is subject to the recommendations and specifications outlined in the Stormwater Report and Stormwater Pollution Prevention
Plan prepared by Jacobs Associates, dated April 2012 (Report) and July 2012 (SWPPP). The report shall remain attached to the approved land
modificatio er it. All recommendations are to be considered to be required conditions of approval.
X
3) Approval is subject to the mitigation recommendations made in the Habitat Management Plan prepared by BioResources (Kim Schaumburg), dated April
2012. All recommendations are required elements.
An inspection letter/report shall be submitted to verify compliance with the approved Habitat Management Plan. The report shall be signed and stamped
by the author of the plan or his or her designee and submitted to the Mason County Department of Community Development prior to final inspection.
Copies of the tion report shall be made available at time of final inspection.
X
4) Compliance with an approved Storm Water Plan shall be subject to an on site inspection, or inspections, by the engineer of record or an authorized
representative. Said inspection(s) shall be performed in accordance with the approved plan, and prior to any modification that would make a
determination of compliance impossible.
Inspection reports shall be submitted to verify all engineering requirements have been completed in accordance with the approved storm water plan.
Reports shall be submitted to the Mason County Department of Community Development prior to each corresponding inspection and final permit
approvals of all special inspection reports shall be made available at time of inspection.
X
5) Hydraulic Proje Approval (HPA) shall be obtained from the Washington Department of Fish and Wildlife prior to beginning any site preparation and
constructio k near water.
X
6) ARCHAEOLOGICAL RESOURCES
Archaeological or historical resources, such as ruins, sites, buildings, artifacts, fossils, or other objects of antiquity that may have significance from an
historical or scientific standpoint, which may be encountered by the developer/contractor, shall not be further disturbed. If the developer/contractor
encounters any such artifacts, he/she shall immediately stop work and notify Mason County and the Washington State Department of Archaeology and
Historic Pri ion. Failure to do so may result in civil penalties.
X
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7) Proper disposal of constru�ebris must be on uplands, in such a manner that debris cannot enter wetlands or cause water quality degradation of
adjacent waters. X
GRD2012-00006 Please refer to the following page(s)for conditions of this permit. Page 2 of 5
8) Access Roads to the site must not be degraded as a result of work. X a')W"
9) ALL CLEARING,CUTTING, GRADING, EXCAVATING, TERRACING, FILLING AND SIMILIAR WORK WILL BE REGULATED BY THE
REQUIREMENTS PURSUANT TO THE MASON COUNTY GRADING PERMIT STANDARDS ADOPTED BY RESOLUTION 141-96 and MASON
COUNTY C?WTLE 14, CHAPTER 14.44.
X
10)
The owner/applicant shall provide to Mason County inspection reports prepared by the engineer record, complying with the requirements as noted in
Chapter 14.44, section 14.44.220 through 14.44.230.
Professional inspection of grading operations shall be provided by the civil engineer, soils engineer, engineering geologist and/or testing laboratory
required in accordance with 14.44.230. Inspection reports shall address rough and final grading work and include as-built conditions as specified in
Section 14.44.230 (a1), (a2), (a3).
The permittee shall notify the Mason County Department of Community Development when the grading operation is ready for final inspection, after all
drainage facilities are installed, erosion control measures are completed and all inspection required reports, prepared by the licensed design
professional(s), have been submitted to Mason County Dept. of Community Development.
X yAUJ
11) 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 further inspections being performed or approvals granted.
X
12) All changes to"approv d" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance or re I do , must be reviewed and approved by Mason County prior to construction.
X
13) A permit is required for land clearing and burning IN ACCORDANCE WITH Mason County Code Chapter 9.48. Burn permit applications are available
through the Mason County Department of Community Development located at 426 West Cedar Street.
X 'M
14) FINAL INSPECTION REQUIRED
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 ordj ces and building regulations.
X
GRD2012-00006 Please refer to the following page(s)for conditions of this permit. Page 3 of 5
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 have pent d action from being taken. No more than one extension may be granted.
X (if/�
16) COMPACTION REPORT
A COMPACTION REPORT PREPARED AND SIGNED LICENSED DESIGN PROFESSIONAL SHALL BE REQUIRED. THE REPORT SHALL VERIFY
THAT FILL MATERIAL HAS BEEN COMPACTED TO NOT LESS THAN NINETY-PERCENT OF MAXIMUM DRY DENSITY. SUBMIT COMPACTION
REPORT(S) TO�T�H�E�MASON COUNTY BUILDING DEPT., PO BOX 186, SHELTON, WA 98584 PRIOR TO THE FINAL INSPECTION.
X Gam')`�'V
17) This permit is approved to stabilize slopes in areas located at and near the 2006 landslide, add new fill to support a new conveyance pipeline, replace
the damaged concrete flume, construct a new access road, construct a mechanically stabilized earth (MSE) retaining wall system, and construct a
groundwater control system beneath the retaining wall and fill.
Inspections shall be performed by the engineer of record, Jacobs and Associates to verify that all permitted improvements are perofmred in accordance
with the approved design. If modifications are necessary as a result of site conditions as-built plans, sealed by the design professional, shall be
submitted with inspection reports.
During construction of the MSE retaining wall weekly structural observation inspection reports shall be submitted to the Mason County building
department. Inspection reports shall begin with foundation and drain work and continue to the final inspection report. The reports shall include
compaction testing to ensure conditions comply with plan specifications.
Grading inspection shall be performed by licensed civil or geotechnical engineers for the following work:
1) Grading operationa including line, grade, and surface drainage of the developed area
2)Welded wire retaining wall system including compaction testing of wall backfill
3) land modification and stormwater controls,
4) conveyance pipeline installation and backfilling.
All Inspection reports shall be sealed by the design professional, include the permit case number(GRD2012-00006), and clearly identify the work
inspected along with results. Submit written inspection reports to the Mason County Building Depat, ATTN Case#GRD2012-00006, 426 West Cedar
Street, Shelton, WA 98584.
X
This permit becomes null and"void if wi ork of 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. Ev' ce of-Eontinuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied.
OWNER OR AGENT: DATE:
C�✓;71 4, IVOVrCh
GRD2012-00006 Please refer to the following page(s)for conditions of this permit. Page 4 of 5
G) r
o CONCRETE MECHANICAL MANUFACTURED HOME F
^' Date B v r
C� Footings 1 Setbacks Ribbons
N Gas Piping
o Interior Date By interior-Date By Date By C
0
Exterior ate y Exterior-Date B Set-
up
INSULATION
Point Load I isolated Footings Date By 0
Date By BG 1 SLAB INSULATION FIRE DEPARTMENT Z
Data B y m
Foundation Wails Floors Date By
Date By Date By DECKS
FRAMING Walls Date By Z
Date By Data By PROPANE TANKS n
PLUMBING Vault Date By p
Date By
OTHER
Groundvrork Attic
Date By Date By Type Z
Date By
Type:
� D.W.V DRYWALL G7
Date By Int Brace Wall Date By
m Date gy FINAL INSPECTION
m Water Line Fire Seperstion O
Date By Date By Date By N
o '
Pass or Request Inspect. c
o Type of Insp. Fail Date Date Done By Comments o
rn
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0
1
_a
0
n
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O
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CD
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Permit# ( 020II akw MASON COUNTY
BUILDING 111 426 W. CEDAR
SHELTON, WASHINGTON 98584
(360) 427-9670
CORRECTION NOTICE
�� .
Job Location � �f N �d�j;,WH,�
This structure has been inspected by Mason County Building Department
and the following VIOLATION of County Laws and Ordinances has been
found: Items listed below must be corrected to gain compliance
! t # c�n w a ► �.., CT tic.<—
You are hereby notified that the above corrections shall be made
BEFORE PROCEEDING WITH ANY FURTHER WORK
❑ Call for re-inspection when corrections are made before continuing ❑ please contact our office
❑ Make corrections, items will be checked on next inspection regarding possible structural
❑ OK to damage incurred by recent
"natural/man made"
❑Thisl is not aJcomplete inspection nn disasters.This is NOT a
Date ! f 17I ( Department CORRECTION NOTICE.
Inspector
Grading Permit --GRD2012-00006 Status ISS o
Activity for GRD2012-00006 o � O
Description Menu Code Date1 Date2 Date3 Assigned To Disp Done By Notes Created Dad
Building Review A100 4/25/2012 6/27/2014 DLC DONE DLC A letter was prepared for mail and delivered to Maureen and Craig via Email. the letter is attache 0 4/2 512 0 1 2
Planning Review A110 4/25/2012 7/1612012 RDH DONE RDH Hold for SEPA and SHX,stormwater,and geotech review-Stormwater Report and Plan and drawin04/25/2012
Documents Received A800 5/23/2012 DONE RDH Revised drawings/plans. No longer proposing rerouting stream- 05/23/2012
H HOLD M500 12/18/2012 6/30/2014 DONE GMM Maurine Kwoloek(Jacobs Assoc)stated that they will be submitting some minor revisions next,12/18/2012
Documents Received A800 6/16/2014 DONE TW revisions received routed 06/16/2014
Approved for Issuance A050 6/30/2014 6/30/2014 DONE GMM 06/30/2014
Issue Grading Permit A500 7/3/2014 DONE GMM 07/03/2014
Print Inspection Card A520 7/3/2014 DONE GMM 07/03/2014
3rd Party Inspection ReB102 9/512014 DONE DLC Received inspection reports for weeks 1,2,&3. See documents attached-DLC 0910612014
3rd Party Inspection ReB102 9/15/2014 DONE DLC Sth week re4pon attached,see document attached 09/15/2014
3rd Party Inspection ReB102 10/3/2014 DONE DLC Week#7,see document attached. 1 0/0 3120 1 4
3rd Party Inspection Re13102 10/14/2014 DONE DLC reports#8 and#9 printed,ailed to file and attached to this case. See documents-dlc 10.14.2 0 1 0/1 4120 1 4
3rd Party Inspection ReB102 10/27/2014 DONE DLC Week 10 report attached to case and added to inspetion card 1 0/2712 0 1 4
3rd Party Inspection ReB102 11/13/2014 DONE DLC Inspection resport,including final inspection report received and attached to this case- Ms Kwolll/13/2014
Final Inspection-Failed B007 11/14/2014 11/17/2014 AIL LDK 1-Per condition#3 on permit a final letter from designee of habitat management plan require app 11/18/2014
3rd Party Inspection ReB102 12/12/2014 DONE RDH The initial monitoring report was submitted by the habitat biologists approving the installation. At08/03/2016
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813126
Conditions Associated With 1:52:18P1\_
Case #: GRD2012-00006
Permit Condition statu Updated
item# Code Title tatus Changed B Tag Date Bye
1) 1 GEOTECHNICAL REPORT NOT MET 7/16/2012 RDH
Geotechnical Report
The approval of this project is subject to the recommendations and specifications outlined in the Geotechnical
Report prepared by Jacobs Associates dated April 2012. The report shall remain attached to the approved
grading permit. All recommendations are to be considered required.
X
2) 1 STORMWATER PLAN NOT MET 7/16/2012 RDH
STORMWATER
The approval of this project is subject to the recommendations and specifications outlined in the Stormwater
Report and Stormwater Pollution Prevention Plan prepared by Jacobs Associates,dated April 2012(Report)
and July 2012(SWPPP). The report shall remain attached to the approved land modification permit. All
recommendations are to be considered to be required conditions of approval.
X
3) 1 HABITAT MANAGEMENT PLAN NOT MET 6/6/2014 RDH
Approval is subject to the mitigation recommendations made in the Habitat Management Plan prepared by
BioResources(Kim Schaumburg),dated April 2012. All recommendations are required elements.
An inspection letter/report shall be submitted to verify compliance with the approved Habitat Management
Plan.The report shall be signed and stamped by the author of the plan or his or her designee and submitted to
the Mason County Department of Community Development prior to final inspection. Copies of the inspection
report shall be made available at time of final inspection.
X
4) 1750 Spec.Insp.Req.Stormwater Eng. NOT MET 7/16/2012 RDH
Compliance with an approved Storm Water Plan shall be subject to an on site inspection,or inspections, by the
engineer of record or an authorized representative. Said inspection(s)shall be performed in accordance with
the approved plan,and prior to any modification that would make a determination of compliance impossible.
Inspection reports shall be submitted to verify all engineering requirements have been completed in accordance
with the approved storm water plan.Reports shall be submitted to the Mason County Department of
Community Development prior to each corresponding inspection and final permit approval. Copies of all
special inspection reports shall be made available at time of inspection.
X
5) 1 HYDRAULIC PROJECT APPROVAL NOT MET 7/16/2012 RDH
Hydraulic Project Approval(HPA)shall be obtained from the Washington Department of Fish and Wildlife
prior to beginning any site preparation and construction work near water.
X
6) 1 ARCHAEOLOGICAL RESOURCES NOT MET 7/16/2012 RDH
ARCHAEOLOGICAL RESOURCES
Archaeological or historical resources,such as ruins,sites,buildings,artifacts,fossils,or other objects of
antiquity that may have significance from an historical or scientific standpoint,which may be encountered by
the developer/contractor,shall not be further disturbed.If the developer/contractor encounters any such
artifacts,he/she shall immediately stop work and notify Mason County and the Washington State Department of
Archaeology and Historic Preservation.Failure to do so may result in civil penalties.
X
7) 90 Water Quality NOT MET 7/16/2012 RDH
Proper disposal of construction debris must be on uplands,in such a manner that debris cannot enter wetlands
or cause water quality degradation of adjacent waters. X
Page 1 of 3 CaseConditions..rpt
8/X2016
Conditions Associated With 1:52:18PV
Case #: GRD2012-00006
Status Updated
Title Status Changed By Tag Date ByA
8) 10 Access Roads NOT MET 7/19/2012 DLC
Access Roads to the site must not be degraded as a result of work.X
9) 153 CHAPTER 14.44 NOT MET 7/19/2012 DLC
ALL CLEARING,CUTTING,GRADING,EXCAVATING,TERRACING,FILLING AND SIMILIAR WORK
WILL BE REGULATED BY THE REQUIREMENTS PURSUANT TO THE MASON COUNTY GRADING
PERMIT STANDARDS ADOPTED BY RESOLUTION 141-96 and MASON COUNTY CODE,TITLE 14,
CHAPTER 14.44.
X
10) 1 INSPECTION REPORTS-ENGINEERED Gf NOT MET 7/19/2012 DLC
The owner/applicant shall provide to Mason County inspection reports prepared by the engineer record,
complying with the requirements as noted in Chapter 14.44,section 14.44.220 through 14.44.230.
Professional inspection of grading operations shall be provided by the civil engineer,soils engineer,
engineering geologist and/or testing laboratory required in accordance with 14.44.230. Inspection reports shall
address rough and final grading work and include as-built conditions as specified in Section 14.44.230(al),
(a2),(0)•
The permittee shall notify the Mason County Department of Community Development when the grading
operation is ready for final inspection,after all drainage facilities are installed,erosion control measures are
completed and all inspection required reports,prepared by the licensed design professional(s),have been
submitted to Mason County Dept.of Community Development.
X
11) 1 APPROVED PLANS ON SITE NOT MET 7/19/2012 DLC
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
12) 1 CHANGES TO APPROVED PLANS NOT MET 7/19/2012 DLC
All changes to"approved"building plans that effect compliance with the international codes as amended and
adopted,or any other Mason County ordinance or regulation,must be reviewed and approved by Mason
County prior to construction.
X
13) 1 OUTDOOR BURNING NOT MET 7/19/2012 DLC
A permit is required for land clearing and burning IN ACCORDANCE WITH Mason County Code Chapter
9.48. Burn permit applications are available through the Mason County Department of Community
Development located at 426 West Cedar Street.
X
14) 1 FINAL INSPECTION REQUIRED NOT MET 7/19/2012 DLC
FINAL INSPECTION REQUIRED
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.
Page 2 of 3 CaseConditions..tpt
8/3/2016
Conditions Associated With 1:52:18PM
Case #: GRD2012-00006
i�
Permit Condition Status Updated
item# Code Title Status Changed By 'fag Date J
X
15) 1 PERMIT EXPIRATION NOT MET 7/19/2012 DLC
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 have prevented
action from being taken. No more than one extension may be granted.
X
16) 1 COMPACTION REPORT NOT MET 7/19/2012 DLC
COMPACTION REPORT
A COMPACTION REPORT PREPARED AND SIGNED LICENSED DESIGN PROFESSIONAL SHALL BE
REQUIRED. THE REPORT SHALL VERIFY THAT FILL MATERIAL HAS BEEN COMPACTED TO NOT
LESS THAN NINETY-PERCENT OF MAXIMUM DRY DENSITY. SUBMIT COMPACTION REPORT(S)
TO THE MASON COUNTY BUILDING DEPT.,PO BOX 186,SHELTON,WA 98584 PRIOR TO THE
FINAL INSPECTION.
X
17) 1 SCOPE OF PROJECT NOT MET 6/27/2014 DLC
This permit is approved to stabilize slopes in areas located at and near the 2006 landslide,add new fill to
support a new conveyance pipeline,replace the damaged concrete flume,construct a new access road,construct
a mechanically stabilized earth(MSE)retaining wall system,and construct a groundwater control system
beneath the retaining wall and fill.
Inspections shall be performed by the engineer of record,Jacobs and Associates to verify that all permitted
improvements are peroommed in accordance with the approved design.If modifications are necessary as a result
of site conditions as-built plans,sealed by the design professional,shall be submitted with inspection reports.
During construction of the MSE retaining wall weekly structural observation inspection reports shall be
submitted to the Mason County building department. Inspection reports shall begin with foundation and drain
work and continue to the final inspection report. The reports shall include compaction testing to ensure
conditions comply with plan specifications.
Grading inspection shall be performed by licensed civil or geotechnical engineers for the following work:
1)Grading operationa including line,grade,and surface drainage of the developed area
2)Welded wire retaining wall system including compaction testing of wall backfill
3)land modification and stormwater controls,
4)conveyance pipeline installation and backfilling.
All Inspection reports shall be sealed by the design professional,include the permit case number
(GRD2012-00006),and clearly identify the work inspected along with results.Submit written inspection
reports to the Mason County Building Depat,ATTN Case#GRD2012-00006,426 West Cedar Street,Shelton,
WA 98584.
X
Page 3 of 3 Caseconditions..rpt
.I ROAD TO
SCHOENING
RESIDENCE w '
IV
40 0 40 80
404
FEET
i
I400, PROPOSED 2:1
CUT/FILL SLOPE
,
410
390 400
390
bg� �o
' \ 380
NEW ACCESS ROAD F — 380 p
tW
vNEK / — 330 I o - 360 �o
E '3 i_
FF G -
E�1O co
350
\ $ oo ,\
• I h� _ 340
WINTER CREEK I �i i
33077,
\ �� �'• .�'�� ��
-7 320
f�7 GATE HOUSE
7; `voi TRANSITION
•EXI'S,TING ROCK TU Wil \ �, 11B0
�o
o 1160
--
310
-- --- --- --- 4",
0 !� 5S EXISTING CONCRETE
FLUME LOCATION
INTAKE STRUCTURE 240
c�
INTAKE AREA REPAIRS
GATE HOUSE I PROPOSED 470 LF 48" \
60'HIGH
\ MECHANICALLY Wo?v° HOPE PIPE \
2 STABILIZED Wo i 330
�0 EARTH WALL o 0
\ ��• ��o SCREEN HOUSE
LILLIWAUP CREEK •• I ��o ��
o/.V EXISTING PENSTOCK
_- _ � '�.
_ � � TO POWERHOUSE
APPROVED I f
2
=# ,SON COUNTY DCD PLANNING 1 3207�
SITE PLAN REQUIRED TO.SE ON SITE
CHANGES SU ET TO APPROVAL SCREEN,;y Die / 1 I• TRANS TIONUSE ROAD TO POWERHOUSE ,
\� FOR PERMIT REVIEW Know what's below.
Call before you dig.
DESIGNED: CHECKED: DATE:
S.MORALES M.KWOLEK LILLIWAUP FALLS POWER PROJECT MAY 10.2012
LANDSLIDE,CONVEYANCE PIPE AND INTAKE REPAIRS JOB NO:
DRAWN: APPROVED: 4435.0
D.LILLY F.PITA DRAWING NO:
Engineers/Consultants HORZSCALE: VERTSCALE: OVERALL SITE PLAN 9
No. REVISION BY APP'D
1"=40' SHEET NO: OF
9 29
IL
FORM MUST BE COMPLETED IN INK PERMIT NO.: GRD-2(� 2" CW-CV
PLEASE PRESS HARD MASON COUNTY
LAND MODIFICATION PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 92584
Shelton 360 27-9670 Beira', 360 275 Elrna 360 -5269 Seattle 206 968
APPLICANT,JN ORMATION�, CONTRACTOR INFORMATION
Owner G / �/! 4+n 4rl E' Contractor Name /�'/y�l F CON rGnCT(1
Mailing Address 14 r! l Mailing dress — SS 7�v '
�T. Za!
City <— State�fr Zip Code f City /�('� '! State 4 Zip Code
Phone(2cy-) -L YCV 4 C Other Ph.(_ Ph.(q2! 53-/ 3i cC) Other Ph.
Lieo/Title Holder Contractor Reg.# �CC
Address Expiration
ENGINEER INFORMATION �^
Name 1?}GOr3 ASSGCf/i'NJ Phone ZC( ,G )
Address 1ZQ2 i c- Si State Zip Code
PARCEL INFORMATION-12 digit Tax Parcel No. Z / -0 (j C' Fire District l
Legal Description tt""
Site Address(inctude et name and city_ E.�
If i t site:
Will timber be cut and sold in parcel preparation? ,e No) k c Sc/A)
LsleefC
Q is your property within 200'of the following:Body o ater(Name)`/7�w�a > r�te� Saltwater
Lake River/Creek ✓ Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs Soft compressible soils I
TYPE OF JOB Excavation i Filling o Y Grading ✓ Total size of area
Size of area to be cleared on slopes over 10/o Estimated amount of cubic yards 1 I
Describe Work
LAND MODIFICATION INFORMATION YES NO
Will fill be brought on site? If yes,source O ¢
Will excavated materials be taken off site? If yes,destination /
Does fill Contain potential hazardous materials? BVIX Cs7/
Has a soils report been completed on site? If yes,include copy. Er— Ell
Will proposal result in redirection of any surface water runoff onto adjacent properties? 0
Will proposed work alter where storm water or round water enters or exits the site?
Will quality,quantity or velocity of storm/ground water be altered? Q---- n \
Will runoff be collected/controlled by interceptors,curtain drains or other collection devices? O
Will the land be replanted upon completion? ❑
Will the proposal result in slopes steeper than those currently on site? g,r
Is the site within 200'of a designated shoreline?
NOTICE: THIS PERMIT BECOMES NULL h VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF 1
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 I
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-]certify that I am exempt from the requirements of CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
the Contractor Registration Law RCW 18.27 and am aware of the 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 ordinance requirements regulating the work for which this permit is issued r+
will be done in conformance therewith. No changes shall be made without and all work shall be done in conformance therewith. No changes shall
first obtaining approval. be made without first obtaining approval.• R`I
X Date X Date
FOR OFF CIAL USE BEYOND THIS POINT
Accepted b n1ii Date Submittal Amount Due Receipt No.
DEPA T ENTAL REVIEW APPROVED DENIED CONDITION CODES
Building Dep ent 1 I
Planning Department vow
Public Works Departme
Fire Marshal
FEES
Grading Permit Fee Co 4 Site inspection
Plan Review Fee 7 Other
Public Works Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES