HomeMy WebLinkAboutBLD2011-00597 Cancelled SFR - BLD Permit / Conditions - 7/11/2002 Inspection Line(360)427-7262
MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone: (360)427-9670, ext. 352
t Mason County Bldg. III 426 W. Cedar P.O. Box 186
Shelton, WA 98584
i�
RESIDENTIAL BUILDING PERMIT BLD2011-00597
OWNER: TOM MARTIN RECEIVED: 7/19/2011
CONTRACTOR: LICENSE: EXP: ISSUED: 8/29/2011
SITE ADDRESS: 191 NE MOUNTAIN VIEW DR TAHUYA EXPIRES: 2/29/2012
PARCEL NUMBER: 223195000096
LEGAL DESCRIPTION: WOOTEN LAKE TRACTS TR 96
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
CARPORT WITH STORAGE AREA
General Information Construction &Occupancy Inform ti n I I Square Footage Information
No. of Bedrooms: Type of Constr.: V
Type of Use: SF Insp.Area: No. of Bathrooms: Occ. Group: ize: Deck:
Type of Work: ACC Fire Dist.: 8 No. of Stories: 1 Occ. Load: Building: Carport-Detached 888
Valuation: $ 21,894.72 Building Height: 10 Occ. Stat : P ' a Basement:
Manufactured Home Information Setback Infor at n Shoreline& Planning Information
Make: Length: Front: 90.0 VShtinFt. Water Body: WOOTEN LAKE
2 0 Ft. Ft. SEPA?: No
Model: Width: Ft. Shoreline Desig.: Urban
S e 1: E t. .O1 AnYear: Serial No.: S e 2: t. (p. I I $ I Comp. Plan Desig.: Rural
Plumbing Fixture nical ixtures FEES
Type Qt T Qty. Type By Date Amount Receipt
Plan Check Fee TW 7/19/2011 $227.01 S120110001
Planning Review Fee TW 7/19/2011 $205.00 S12011000i
EH Plan Review KKK 7/19/2011 $103.00 S620110001
Building State Fee LDK 8/18/2011 $4.50 S12011000(
Building Permit Fee LDK 8/18/2011 $349.25 S1 201 1 0001
Total $888.76
BLD2011-00597 Please refer to the following pages for conditions of this permit. Page 1 of 5
CASE NOTES FOR
BLD2011-00597
CONDITIONS FOR
BLD2011-00597
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
1-800-64�-0982. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
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2) Owner/Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
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3) Prior to final approval, all upland areas disturbed or new y created by construction activities shall be seeded, vegetated or given an equivalent type of
erosion protection (silt fencing or straw matting). X
4) Approved per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
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5) Applicatian acknowledges that the structure is only permitted for a use consistent with the current zoning of the parcel. Zoning is Rural Residential 5.
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6) ALL SURFACE WATER AND POTENTIAL RUNOFF WILL BE CONTROLLED ON SITE AND SHALL NOT ADVERSLY AFFECT ANY ADJACENT
PROPERTIES NOR INCREASE THE VELOCITY FLOW ENTERING OR ABUTTING TO ANY STATE OR COUNTY CULVERTING/DITCHING SYSTEM
02 RQ40-WAY.
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7) By definition, propane tanks and heatpumps are structures, which must meet setback conditions. Please check your"Approved Site Plan"to ensure
these structures meet the setback conditions listed.
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8) Landings and stairs must meet the same setback conditions as any permitted structure; and, must be shown on your site plan. Please check your
"Ap,provgtd Site Plan" to ensure these structures are shown and meet the setback conditions listed.
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BLD2011-00597 Please refer to the following pages for conditions of this permit. Page 2 of 5
9) Owner/builder assumes all responsibility if drainfield/reserve area is encumbered.
A. Drainfield/ Reserve requires a 10ft setback from all footing/foundations.
B. Septic tank(s) requires 5ft setback from all footing/foundations.
C. No fqgp2dation drains within 30ft, down gradient of drainfield/reserve area.
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10) 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
DepartrrL t�ior to any further inspections being performed or approvals granted.
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11) 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 o a roved documents will result in failure of required building inspections.
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12) This structure is approved as un-heated space. If at any time this building is to be used for anything other than what it is approved for, a change of use
permit shall a applied for, reviewed and approved prior to the change.
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13) THE FOUNDATION SYSTEM SHALL BE PLACED ON UNDISTURBED, NATIVE SOIL. X
14) 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 D artm rior to any further inspections being performed or approvals granted.
X
15) A Mason County Stormwater Management Worksheet was completed and signed as part of this building permit application. Design, sizing, placement,
inspection and maintenance of stormwater management systems shall be the responsibility of the owner/agent of the developed parcel. It is the
owner/agent/contractor's responsibility to ensure that Mason County Department of Public Works has approved the stormwater site plan for this parcel
prior to the commencement of any development activities. `NOTE if Stormwater Management option "A"was selected on the Small Parcel Stormwater
Management Application/Worksheet the document entitled "Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan"constitutes
an approved plan based on the criteria listed on the application/worksheet. If the development has, or will have, a septic/drainfield system you are
responsible for contacting Mason County Division of Environmental Health to ensure that the stormwater system will not adversely affect the septic
system of this, or any other, parcel. You may also wish to consult with the septic design professional involved with the project. By calling for a final
inspection of the building permit the owner/agent/contract iq� s acknowledging that all components of the stormwater management system have been
installed as approved on the stormwater site plan. X ;71�
16) 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).
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BLD2011-00597 Please refer to the following pages for conditions of this permit. Page 3 of 5
17) This structure is limited to U-occupancy use only(private garages, carports, sheds, and agricultural buildings.) Any other use will be in violation of the
international codes and Mason County Regulations unless a"Change of Use" permit is applied for, reviewed and approved.
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18) Any changes in proposed construction shall be reviewed by the engineer or architect of record and submitted in writing to the Mason County Building
Department prior to construction. All engineering and/or architectural documents are a part of the approved set of plans and shall remain attached
thereto. If documents are removed, 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 prior to any further inspections being performed or approvals granted.
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19) All construction must meet or exceed all local ordinances and the international codes requirements as adopted and amended by Mason County and the
State of Washington. Occupancy is limited to the approved and permitted classification. Any non-approved change of use or occupancy would result in
permit revo_ c,ption.
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20) 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 proje
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21) Placemept,of structure must comply with standards set forth per the international codes regarding descending and/or ascending slopes.
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22) 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.
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23) 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
Inspectshall be made prior to requesting additional inspections.
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24) All property lines shall be clearly identified at the time of foundation inspection. X
25) 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
M! �ordinances and building regulations.
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BLD2011-00597 Please refer to the following pages for conditions of this permit. Page 4 of 5
26) 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 h ve prevented action from being taken. No more than one extension may be granted.
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27) Pressure treated wood manufactured after January 1, 2004 may contain high concentrations of copper which could quickly corrode metal fasteners,
conner,tgrs, and flashing. Install metal connectors approved for contact with the new types of pressure treated material.
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28) Retaining walls needed to support a surcharge such as structures, roads, or to support slopes, shall require a separate building permit and approval prior
to construction of the retaining wall. X c7r—
This permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended for a period of 180 days at any
time after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be
occupied. Proof of continuation of work is by means of a progress inspection.The owner or the agent on the owners behalf, represents that the information provided is accurate
and grants employees of Mason C inty access to a above described property and structure for review and inspe tio/n.
OWNER OR AGENT: DATE:- 6-9 �(
BLD2011-00597 Please refer to the following pages for conditions of this permit. Page 5 of 5
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to
o CONCRETE MECHANICAL MANUFACTURED HOME
Footings !Setbacks GDaasePiping By Ribbons �
o Interior Date By Interior-Date By Date By Z
Cn
Exterior Date �� By Exterior-Date_ By Setup O
Point Load I Isolated Footings INSULATION Dale By 3
BG!SLAB INSULATION - -
Date By Data By FIRE DEPARTMENT
Foundation Walls Floors Date By
Date By Data By DECKS
FRAMING Walls Date By
Date By Data By PROPANE TANKS
PLUMBING vault Dato By
Date BY OTHER _--
Groundwork Attic
Date By Date By TypeDate By
D.W.v DRYWALL Type-
Date By
Int.Brace Wall Date By W
Date By FINAL INSPECTION
y Water Line Fire Seperation N
Date By Date By Date By
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g Pass or Request I nspect. c
Type of Insp. Fail Date Date Dane By Comments CD CA
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Permit# //-C� MASON COUNTY
BUILDING 111 426 W. CEDAR
SHELTON, WASHINGTON 98584
(360) 427-9670
CORRECTION NOTICE
Job Location /q / 1y1WNI'-}1'''V
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 s
p .yam i cci
L c=4 nf oG ,-1 L>c�m,�
S ,✓�- ,� �rcr ire ' �aX �._yr- - z
You are hereby notified that the above corrections shall be made
BEFORE PROCEEDING WITH ANY FURTHER WORK
14 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"
❑This is not a complete inspection disasters.This is NOT
Date / —/ / —1 2. Department C CORRECTION NOTICE.
Inspector /' 1-
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SITE PL R E"
'j SIT�ON
PRO�AL
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ON SITE
41V C HA Nlr�
Su D" F TO APPROVAL
Date Z/
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P N G :
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A LS BACKSAREM EASURED
FROM THE FURTHEST
ROJECTION OF THE BUILDING
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9
t '�� PLANNING
I scT RECEIVED
NOV 15 2011
Do
:7Ait i NJ 426 W. CEDAR ST,
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PLANNING :
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ALL SETBACKS ARE MEASURED
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FROM THE FURTHEST
PROJECTION OF THE BUILDING
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APPROVED
MASON GiUlt!TY D'k.3D PLANNING I eg-
SITE PLAN REQURED TO BE ON SITE j jjj
CH6NGES SUBJECT TO APPROVAL \1
By
Date .10, 00 Iq
I L40
coAST TO COAST tt ORTS 22525 ntrsatOa e,AR.
R P.O. OO KnoxviAR. 72845
,l�v Business (479) 885-1258 Fax (877) 472-5097
Tall Free 1-866-267-3790
Dealer:
Lo&WeNgjCatP0d 360'608-7M County: ��D�r7� Phone:
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Buyer Name: girl— + tom✓�` — ``''��
1 �'�c4✓f I ", Ql` City:�� State:_cif'= ----... —
Buyer Address: ec
�1 �.7�
Phone(Day) 1C r (� 7� (Evening) _ (Cell) --
Unit Location (If different from above) :_
OPTIONS CARPORT ❑ UTILITY CARPORT GARAGE CJ RED BARN ❑ GE
RTIFIEDi)� NON-CERTIFIED
REG. STYLE ❑ 14 Ga❑ 12 Ga❑ WIDTH X LENGHT $ All Orders C.O.D.
X HEIGHT $ -7 —7 0)
A-FRAME STYLE 0 14 GaAN 12 Ga.(l WIDTH 7jC f X LENGHT 5 S 2 ! Puce_ S.-1 S7Q
X HEIGHT $
ROOF LE
NG i t'. _ FRAME LENGTH_.._._-_- .- ✓F RTI(;AL boor $ tax
COLOR TOP TRIM $
GABLE ENDS COLOR Frt0N1 yAc.e ❑ HOTH ❑ $
2' r,N, ❑ Iin1H $ Document
SIDES CLOSED cu uk 15Z w
VLHrIGA;, SIDS v $ Fee $
CLOSED ENDS rIN+- W � t�
vL rt nr:n: N•i= — $ Total
S a( 1}7, `
GARAGE DOORS i,r YA1 r.u•.Nv, f ;VF fp OTHER .L r. $
WINDOWS 11uw MANY.' $ 104u Down
WALK-IN DOORS flow n+nNv' $ Payment •7CJ7,00
EXTRA PANELS HCiw 0.1ANY': SIZE' GUL OR $ Before Taxes..S-._
EXTRA.BRACES I'uw ^.1;'-NV I SIZE $
SIL[. $
U',AI Il 1 e
EXTRA FRAME BOWS ', MANY'p
F' ss ,
MOE+LE HOME ANCHORS $ r
CONCRETE ANCHORS
ROLL-UP COMMERCIAL DOORS WITH�CHAIN. oVii MAN11-EXTRAS a d ., — 1c`k ` $ �� - Balance Due 24
At installation,S ,—__
TOTAL 15 D
ELECTRICITY AVAILABLE CFML-NT cak,JuNu O OTHER O
Things you should Knovv... + -V I q v
?,) eq 4)
Please Inform In,ta:<<:rS of any underground Cables. gas Imes. or any other ut!llty Imes- if utilities are of marked.we will not be liable for damage.
W,- Ndi 'tot be rr;;p InSlble for hermit, or restrictions. R e..
LOT MUST BE LEVEL OR UNIT WILL BE INSTALLED "AS IS" ON LOT I
!f I:,nd i not I d any additionafmat rial costs will be added to the balance.
_jr additions are to be made to carport. a S100.00 service chargo. an
COAST TO COAS" ,APPORTS INC.WILL RESOLUTELY NOT BE RESPONSIBLE FOR REFUNDS OFT-E CUSTOMER'S DEPOSIT COLLECTED BY THE DEALER.
COAST TC r'OAS; {I,RPORTSANC.IS NOT LIABLE FOR ANY DAMAGES AS A RESULT FROM INCLEMENT WEATHER.
IF YOU AR.TAX EXEMPT.A TAX EXEMPT CERTIFICATE MUST BE ATTACHED TO YOUR ORIGINAL ORDERiS1.OTHERWISE.APPLICABLE TAX WILL BE ADDED.NO EXCEPTIONS
Ot:r ground anchors are temporary only. For permanent anchors ask your Dealer or Sales Representative.
I ba>a r.:Ill Ill.: t=lrrn.- -111d conaillons of INS contract: by signing this contract, I anre?to all Conditions set forth herein and should I fall to make
pavment It:foll at time of delivery I understand and agree to al,ow COAST TO COAST CARPORTS, INC. to pick up the carport and I will be labia
for a:i appl,cahle ci;jrges and fees associated with the initial setup and delivery as well as any legal fees incurred by Coast to Coast Carports. Inc.
Please ke,�p crlglna+ invoice for legal matters. COAST TO COAST CARPORTSANC. RESERVES THE RIGHT TO CANCEL ANY ORDERS.
NOTE. Frarr•,h I; 1 it. 'Shorter than roof length cn horizontal metal.Vertical building,-, rlale no overhang and are 1 ft. shorter than horizontal.
NOTE:If yui;art 1100ding .i spec;al drawing for yore boilding there will be ,tr "dCltiOnAl charge.
BUYER MUST INITIAL WARRANTY SELECTION
See Limited Warranty Explainations on Reverse S
lg GAUGE-Workmanship Only 12 GAUGE-Workmanship&Rust-Through Certified Non-certified
If accepted below by COAST TO COAST CARPORTS,INC. (Seller) at its office in Knoxville,AR. this order becomes
a contract between Seller and the Buyy�er named below as follows: subLect to the terms above and
vySUBJaaECT TO THE TERMS.AND CONDITIONS ON THE REVERSE SIDE
Seller
Ins site t aT,ihetaddress Seller will
above)anduyrBuyertwialt obtadn ally required perms above
prepare the site for Installation, purchase 'It
pay thg,price as stated above.
NO REF'UNOS ONTA_M RDERS
BUYER D E WITNESS ACCEPTED:
•.• »•w..,«'.;•^ ^' ^•"°""" Coast to Coast Carports,Inc.
1
Name 1l, Parcel# ,J l� _/ D#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 1 of 2)
Per Mason County Code,Title 14,Chapter 14.48 a stormwater site plan is required whenever a building application is
made for residential development,or redevelopment',with more than 2,000 square feet of impervious surface 2.
'Redevelopment means,on an already developed site,the creation or addition of impervious surfaces,structural development
including construction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not
part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment.
2Common impervious surfaces include,but are not limited to,rooftops,walkways,patios,driveways,parking lots or storage areas,
concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the
natural infiltration of stormwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
To Calculate Impervious Surfaces Please Complete This Table'
Surface Type Length X Width = Area *All dimensions in feet
Buildings X
X = Measurements for buildings are taken at the
_ perimeter of the farthest projections(example:X
eaves/gutters)
X =
Driveways X =
X = Length of drive begins at the right of way
X =
Parking Areas X
X = Any paved, gravel or packed area per definition
above table
X =
Patios/Walks X
X = Any paved, gravel or packed area per definition
above table
X =
Others X
X = If the total impervious area of the proposed site
X = development is greater than 2000 square feet a
Small Parcel Stormwater Site Plan is Required
Total Impervious Surface Area(sum of all areas)
If the Total Impervious Surface Area is LESS THAN 2000 Square Feet, please read,acknowledge and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative,or the contractor.I
further acknowledge that the informatio provided is accurate and employees of Mason County are granted access to the above-
described property for r v. and insp tion as may be required.
o
X Owner/Agent/Contractor(circle one)Date:
If the Total Impervious Surface Area is GREATER THAN 2000 Square Feet, please read,acknowledge and sign
the information provided on page 2 of 2.
Page 1 of 2
Name Parcel# BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 2 of 2)
Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity.
Title 14, Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater
Management in this jurisdiction.A complete copy of the ordinance can be found on the Mason County website:
http//www.co.mason.wa—us/code/commissioners/index.htm
Please follow the links to "Title 14,Chapter 14.48 Stormwater Management".
Regulated activities shall be conducted only after Mason County Public Works approves a stormwater site plan
(Mason County Code Title 14 Chapter 14.48 section 14.48.70). You will receive a copy of the Public Works document
entitled "Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan".This document will assist
you in preparing the necessary information and plans for Public Works to review and approve. Per Department of
Public Works this document will constitute an approved plan if all of the relevant details* are to be installed in
their entirety AND no part of the stormwater system adversely affects any septic system (see Environmental Health
information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval.
A design by a registered professional may be required for more complex sites.
*These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan
on the pages that begin with"Handout"
PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE
A) The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
in their entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel.
B) An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the
system will be located as not to adversely affect any septic systems on this,or any other,parcel.
If you have further questions pertaining to parcel drainage and Stormwater management Mason County's Public Works
Department can provide additional instructions,guidance and examples. (Section 14.48.130)contact Public works at:
Phone: (360)-427-9670 EXT.450
Mail: P 0 Box 1850, Shelton WA 98584
Physical:415 N 6th St,Shelton WA 98584
If this development has, or will have,a septic/d ra infield system you may need to contact Mason County Division of
Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or
any other,parcel. You may also wish to consult with the septic design professional involved with the project.Mason
County Division of Environmental Health can be reached at:
Phone: (360)-427-9670 EXT.352
Mail:P 0 Box 1666, Shelton WA 98584
Physical: 426 W Cedar St, Shelton WA 98584
A condition will be added to the building permit that states, in part,that all conditions the stormwater site plan will be met
prior to a request for final inspection of the building permit.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative,or the contractor.I
further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above-
described property for review and inspection as may be required.
X Owner/Agent/Contractor(circle one)Date:
Page 2 of 2
I
MASON COUNTY PERMIT NO. &hD-)0I -t i7
BUILDING PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-9670•Belfair(360) 275-4467• Elma (360) 482-5269
On the web www.co.mason.wa.us
APPLICAN INFORMATION CONTRACTOR INFORMATION
Owner 8 rn.4 Y Company Name
Mailin Address J,' ) pe�' �7`-5 f.J Mailing Address
City )r State 1,2 P Zip Code q ' '12- city State Other Ph.
ode
Phoneme 0� f 9 9 2±2 rather Ph 3 „.�0 7 6v7 b Phone
Lien/Title Holder Contractor Reg. # Exp.
E mail address _;PT4-
It ) / 7-C, A a/,71 0 LA E Mail Address
Drivers Lic.# Z 4 Ri T�)� '�5f R�Z- Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Water System Name of Water System
PARCEL INFORMATION- 12 Digit Parcel No -'7 - 0 10 Fire District
Legal Description
Site Address(Please include street name, street number and city)
Directions to site
Will timber be cut and sold in parcel preparation?Yes/KQr
Is property within 200'of Saltwater Lake River/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/No
TYPE OF JOB -New Add Alt Repair Other PRIMARY RESIDENCE ❑ SEASONAL ❑
Use of Building r4A�4 i; ✓`i Describe Work
No. of Bedrooms No. of Bathrooms Square Footage-1 st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage 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.
OVVNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employ of Mason County access to the above described property d structure for review and inspection.
PRO
OFNTINUATI OF W K IS BY MEANS OF A PROGRESS INSPECTION.
X 2 '7�G�^^ Date ey�
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department Val
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Buildinq 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 I State Fee
Violation Fee L Pre-Paid at Submittal
Valuation $ TOTAL FEES