HomeMy WebLinkAboutBLD2005-00915 Final MFG Home - BLD Permit / Conditions - 1/17/2006 • Inspection Line(360)427-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone (360)427-9670,ext. 352
Mason County Bldg. III 426 W. Cedar P.O. Box 186
Shelton, WA 98584 0 I
1p;i f 5i
RESIDENTIAL BUILDING PERMIT BLD2005-00915
OWNER: WILLIAM ELLIOTT
CONTRACTOR: BUTCH'S BULLDOZING (360) 275-5541 LICENSE: BUTCHB1994QE EXP: 11/5/2005 RECEIVED: 6/2/2005
ISSUED: 9/9/2005
SITE ADDRESS: 51 NE ERICKSON DR BELFAIR EXPIRES: 3/9/2006
PARCEL NUMBER: 223047500020
LEGAL DESCRIPTION: TR 2 OF SURVEY 4/120
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW MANUFACTURED HOME - 2005 FLEETWOOD BEAR CREEK DEWATTO PROCEED PAST BLACKSMITH LAKE ROAD TO
ERICSON LANE. JUST BEFORE ERICSON LAKE ROAD FIRST LOT ON
LEFT.
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: 4 Type of Constr.:
Type of Use: MH Insp. Area: No. of Bathrooms: 2 Occ. Group: R-3 Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No. of Stories: 1 Occ. Load: Building:2,563
Valuation: Building Height: 14 Occ. Status: Primary Basement:
Manufactured Home Information Setback Information Shoreline & Planning Information
Make:FLEETWOC Length: 66 Ft. ,Front: W 158.0 Ft. Shoreline: Ft. Water Body:
// Rear: E 305.0 Ft. Slope: Ft. SEPA?: No
Model:7664B Width: 40 Ft. Side 1: N 180.0 Ft. Shoreline Desig.: Not Applicable
Year:2005 Serial No.: Side 2: S 80.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures FEES
Mechanical Fixtures
Type Cty. Type 0 ty. a By Date Amount Receipt
Mobile Home Submittal Fee CMH 6/2/2005 $214.50 B12005
Planning Review Fee CMH 6/2/2005 $155,00 B12005
Building State Fee ARC 6/8/2005 $4.50 S22005
Mobile Home Issuance Fee ARC 6/8/2005 $214.50 S22005
Address Fee GMM 8/9/2005 $140.00 S22005
EH Plan Review ADR 8/18/2005 $75.00 S22005
EH Permit Revision CEW 9/8/2005 $35.00 S22005
Additional Plan Check Fee ARC 9/9/2005 $58.00 S22005
Total $896.50
r
'712005-00915 Please referto the following pages for conditions of this permit. 1 of 5
Inspection Line(360)127-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427-9670,ext. 352
Mason County Bldg. III 426 W. Cedar P.O. Box 186
Shelton, WA 98584
RESIDENTIAL BUILDING PERMIT BLD2005-00915
OWNER: WILLIAM ELLIOTT RECEIVED: 6/2/2005
CONTRACTOR: BUTCH'S BULLDOZING (360)275-5541 LICENSE: BUTCHB1994QE EXP: 11/5/2005 ISSUED: 9/9/2005
SITE ADDRESS: 51 NE ERICKSON DR BELFAIR EXPIRES: 3/9/2006
PARCEL NUMBER: 223047500020
LEGAL DESCRIPTION: TR 2 OF SURVEY 4/120
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW MANUFACTURED HOME - 2005 LIBERTY INDEPENDENCE BEAR CREEK DEWATTO PROCEED PAST BLACKSMITH LAKE ROAD TO
ERICSON LANE. JUST BEFORE ERICSON LAKE ROAD FIRST LOT ON
LEFT.
General Information Construction &Occupancy Information Square Footage Information
No. of Bedrooms: 4 Type of Constr.:
Type of Use: MH Insp. Area: No. of Bathrooms: 2 Occ. Group: R-3 Lot Size: Deck:
Type of Work: NEW Fire Dist.: 2 No.of Stories: 1 Occ. Load: Building:2,563
Valuation: Building Height: 14 Ooc. Status: Primary Basement:
Manufactured Home Information Setback Information Shoreline&Planning Information
Make:FLEETWOC Length: 66 Ft. Front: W 100.0 Ft. Shoreline: Ft. Water Body:
Rear: E 390.0 Ft. Slope: Ft. SEPA?: No
Model:7664B Width: 40 Ft. Side 1: IN 125.0 Ft. Shoreline Desig.: Not Applicable
Year:2005 Serial No.: Side 2: S 225.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures FEES
Mechanical Fixtures
Type Qty. Type be By Date Amount Receipt
Mobile Home Submittal Fee CMH 6/2/2005 $214.50 B12005
Planning Review Fee CMH 6/2/2005 $155.00 B12005
Building State Fee ARC 6/8/2005 $4.50 S22005
Mobile Home Issuance Fee ARC 6/8/2005 $214.50 S22005
Address Fee GMM 8/9/2005 $140.00 S22005
EH Plan Review ADR 8/18/2005 $75.00 S22005
EH Permit Revision CEW 9/8/2005 $35.00 S22005
Additional Plan Check Fee ARC 9/9/2005 $58.00 S22005
Total $896.50
BLD2005-00915 Please referto the following pages for oonditions of this permit. 1 of 5
CASE NOTES FOR
BLD2005-00915
CONDITIONS FOR
BLD2005-00915
1) 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
Departure for to an further inspections being performed or approvals granted.
X
2) 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 a d the international codes will be assessed if the owner and/or contractor fail to post the address on site prior to requesting
inspections.
X
3) 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 appr ved documents will result in failure of required building inspections.
x d
4) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X
5) 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
Building Department EZ��
o an further inspections being performed or approvals granted.
X
6) 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
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
BLD2005-00915 Please referto the following pages for conditions of this permit. 2 of 5
7) 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 contact the Offfice of Manufacturing Housing (360)725-2800.
8) The internatioanl 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 con ct with a ounty maintained public road or to another fire apparatus access road which connects to a county maintained public road.
X
9) 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 revocation. 1
10) 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 been
discovered. I further understand that this investigation will be scheduled as ti a al ows. Until resol'ion of any/all problems no occupancy(Final
Inspection)will be granted for the residence.
OWNER/CONTRACTOR(indicate which)Signature X
11) This permit is for the placement nd installation of the manufactured home only and does not imply approval or review for any other items indidcated on
the plot plan. X
12) 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 withi 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.
X
13) All changes to"approved" buildin plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinance or regul do must be eviewed and approved by Mason county prior to construction.
X
14) 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 be a r o questing additional inspections.
X
BLD2005-00915 Please referto the following pages for conditions of this permit. 3 of 5
15) 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.
16) All property lines shall be clearly identified at the time of foundation inspection. X
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 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 ordina e hd building regulations.
X r
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 exceeding 180 days, upon the receipt of a written extension request indicating that circumstances beyond the control of the permit
(older have prevented actin from Bing taken. No more than one extension may be granted.
19) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
connectors, and f Inst I metal connectors approved for contact with the new types of pressure treated material.
X
20) OWNER MUST SHOW PROOF OF WELL L(?G AND ND SATISFACTORY WATER SAMPLE PRIOR TO TEMPORARY/PERMANENT OCCUPANCY
OF THE RESIDENCE. X U'.
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21) 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 per?on signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
X
22) Water quality i n to e de r ded to the detriment of the aquatic environment as a result of this project.
X
23) Prior to final approval, all upland areas disturbed or newly created y cons' tion activities shall be seeded, vegetated or given an equivalent type of
erosion protection (silt fencing or straw matting). X
24) Approved perdimensiionsan setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
X
BLD2005-00915 Please refer to the following pages for conditions of this permit. 4 rf 5
1
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 anytime after work is
commenced. Evidence of continuation f ork is a progress insp on within the 180 day period. Final in ped' n must be approved before building can be occupied. Proof of continuation of
work is by means of a progress inspec i .The owneror the a nt n the owners behalf,represents tha he i formation provided is accurate and grants employees of Mason County access to
the above described property an str ture for rev' and in ectl n.
OWN ER OR AGENT: GC DATE: G Q
I
BLD2005-00915 Please referto the following pages for conditions of this permit. 5 of 5
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CONCRETE MECHANICAL MANUFACTURED HOME
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BG I Stab Insulation Floors FINAL I NSPEGTION
Date B y bate By Date - f9 e,By <
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Request To Revise An Approved Plan/
C • I \ �l '�
Permit Number: BLD200,r)—, � i� Name
Parcel Number _ Phone Number daytime
Proect Address Mailing Address
Please provide a complete, detailed description of the proposed revisions to the approved plans:
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes, Is a revised site plan,with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature
Date:
Office Use Only Received by:
Date Sent Assigned To Approved By Date
B. Original Valuation: $
y� ' l `�,, Additional Valuation: $
P. C 1 Sq.Ft. x$ $
E.H. ' Total New Valuation $
P.W. Additional Fees:
Additional Planning Dept. $
New Setbacks: Front / Additional Plan Review $
Rear / Additional Building Permit $
Sidel. J Side2 / Additional Plumbing $
Addit'onal Conditi ns/ o meets: Additional Mechanical $
7 / 1 Additional E.H.Dept. $
Other $
Total Amount Due: $ �(�
Amount To Be Paid Up-Front$
r«n kftw
R&4wd SRG B(=W3
Request To Revise An Approved Plan
Permit Number: BLD200
�
C - Name_
Parcel Number ?- '
- - Phone Number da time�!)
Project Address Mailing Address
Please provide a complete, detailed description of the proposed revisions to the approved plans:
c ;
47-1
1
7
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the.revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
jNote:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes, Is a revised site 1 with all new setback
plan, dimensions included with this re
quest?
❑ Yes ❑ No
Additional Information:
Applicant's signature
Date:
Office use Only Received by:
Date sent Assigned To Approved By Da
g. Original Valuation: $
9 9 Additional Valuation: $
P. Sq.Ft x$ $
Sq.Ft. x$ $
E.H. Total New Valuation $
P.W. Additional Fees:
Additional Planning Dept. $
New Setbacks: Front / Rear / Additional Plan Review $ S Q , p
Additional Building Permit $
Sidel. / Side2 Addition/ al Plumbing $
Ad itional tnditi ns/Com ents: Additional Mechanical $
Additional E.H.Dept. $
Other $
Y� r Total Amount Due: $ '5 8 • no
Amount To Be Paid Up-Front$
� T«a dWi
RevtW SRG 912ZI oa
xrquust 1 U n,evise An Approved Plan
Perr<nit Number: BLD200 Nam
r 1 r
- ` e ( 1 l i C �
Parcel Number - - Phone Number da ime
Project Address Mailing Address
Please provide a complete detailed description f the propos revisions to the approved plans:
y
B
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the.revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
(Note:No structural changes to a"designed"Plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes,Is a revised site plan,.with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature Date:
Office Use only
Received by.
Date Sent Assigned To Approved By pate
$ 71
, 7 n C original valuation $
1 Additional Valuation: $
Sq.Ft. x$
$
Sq.Ft. x$ $
,E.H. (Ertl l� Total New Valuation $
P.W. / Additional Fees:
Additional Planning Dept., $
New Setbacks: Front / Additional Plan Review $
Rear / Additional Building Permit $
Side1. / Side2 / Additional Plumbing $
Additional Conditions/Comments: Additional Mechanical $
Additional E.H.Dept. $
Other $
Total Amount Due: $
Amount To Be Paid Up-Front$
tech:ia.i
Revise)SRG W2ZI W3
teequest ro Revise An Approved Plan
Permit Number: BLD200�- r _ Name_ (�-��,
Parcel Number - - Phone Number da ime
Project Address Mailing Address
Please provide a complete, detailed description of the proposed revisions to the approved plans:
c �
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
f Me:No structural changes to a"desizried"plan will be approved without the written consent of the engineer and/or architect of record
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes, Is a revised site plan,with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature
Date:
Office Use Only Received by:
Date Sent Assigned To Approved By Date
FPB.
�E
Original Valuation:
Additional Valuation: $
Sq.Ft. x$ $
y Ulf Sq.Ft. x$ $
ii E.H. Total New Valuation $
P.W. Additional Fees:
Additional Planning Dept. $
New Setbacks: Front / Rear / Additional Plan Review $
Additional Building Permit $
Side1, / Side2 / Additional Plumbing $
Ad itional Qonditi4pns/Com ents: Additional Mechanical $
Its Additional E.H.Dept. $
Other $
Y� Total Amount Due: $
Amount To Be Paid Up-Front$
r«a�till
Request To Revise An Approved Plan
Permit Number: BLD200 '
�[�� Name �
Parcel Number - - Phone Number daytime (__)
Project Address Mailing Address
a,L Please provide a complete, detailed description of the proposed revisions to the approved plans:
c ti
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this revision? ❑ Yes ❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes, Is a revised site plan,.with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature
Date:
Office Use Only Received by:
Date Sent Assigned To Approved By pate
B. Original Valuation: $
Eh
Additional Valuation: $
P. � Sq.Ft x$ $
Sq.Ft. x$ $
E.H. Total New Valuation $
P.W. Additional Fees:
Additional Planning Dept. $
New Setbacks: Front 1 Rear 1 Additional Plan Review $
Additional Building Permit $
Side1. / Side2 / Additional Plumbing $
Ad itional onditi ns I Corn ents: Additional Mechanical $
Additional E.H.Dept. $
Other $
f� 1 Total Amount Due: $
Amount To Be Paid Up-Front$
// R
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`.-r/n�t I0� �' T� � ' 1 •'_ �,-+ ' 1 evlSed SRCa 9f2112003
e_,WU fl S 1 cOn T1L7 VV1
MASON COUNTY PERMIT N0.C)(lu5f 00
BUILDING PERMIT APPLICATION r--
426 W. CQdar • 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
APPLICAN�NFORMATION CONTRACTOR INFORMATj ON
Owner / /I-L- GY-L f0?7- Company Name
Mailing dres 717,76 / . L g9ry� Mailing Address
City N �ateW'9Zip Code 05� City '/ �-�--� State ZipCodg SPhone z Z-Lr Ph. Phone U- S'S�u IO�pr Ph. 7,/Lien/Title Holder o�� ,4 E Contractor Reg.# U
E mail address E Mail Address
Drivers Lic. # F L L-i o 5 L 5C 2e SOB Drivers Lic.# S -�' 6IDOB z y 7
SEPTIC/WATER SYSTEM INFORMATION - Connect to New Septic _ Existing Septic
Connect to Water System Name of Water System r,:-c L /
Well_ Y Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. 2 77 o " 77 r C c- Z Fire District
Legal Description r /' 'Z r 5"el
Site Address (Please include street name, street number and city)— R ' 5 �`' N
Directions to ite .V-0 k �c'a I �C e v e C�A'r A 5•,vu iTH
Lk 0 I-C) t2teSojj &I• v5 uA-f-_ 5oo-J 4 2 . 71957-
�T c
Will timber be cut and sold in parcel preparation?Yes /No /
Is property within 200'of Saltwater Lake River/Creek- N L' Pond �` U
Wetland ! 0Seasonal Runoff Stream Slopes or Bluffs 1 15% 1y
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 PI�I •IMAPX RESIDENCE SEASONAL ❑
Use of Building -1�- ° '`° Descrit�V/_grk - c� `_l�'' //�s
No. of Bedrooms � No.of Bathrooms-C-`o Sauare Footage- 1 st Floor 2nd Floor
3rd Floor Basement Deck fCo�,Covered Deck Other. Sq.ft.
Garage �O ttached Detached _ �Carport Attached D tached
MANUFACTURED HOME INFORMATION - Make FL, rF U)0C' f- Model. Year
Length f'r Width �erial No. 3/�/ No.of Bedrooms N�.;,iathrooms -
Type of Heat or.a a-u P rchase Pri $ �` Replacement Unit? YeInstaller Name �� 7A/ 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(pro sed in he application, I have obtained permission from them to ply f this permit and conduct the work proposed.
X Date: /� o
Owner/Owners Representative/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 r Y) l tU
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing & Base Fee Planning Review Fee
Mechanical & Base fee Other
Wood/Gas/Pellet Stove Fee State Fee • �d
Violation Fee /VO eA)Ir' Pre-Paid at Submittal
Valuation $ z 4 00 - TOTAL FEES