HomeMy WebLinkAboutBLD2010-00740 Final SFR - BLD Permit / Conditions - 7/1/2015 ' 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 ,
RESIDENTIAL BUILDING PERMIT BLD2010-00740
OWNER: TOM CROSSWHITE RECEIVED: 8/20/2010
CONTRACTOR: LICENSE: EXP: �I r /// ISSUED: 9/12/2011
SITE ADDRESS: 203 NE RANCH DR TAHUYA R,;e' EXPIRES: 3/12/2012
PARCEL NUMBER: 223293490020 nv
LEGAL DESCRIPTION: LOT: 1 OF SP#2990 PTN TR 2 S 8/150
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
NEW SFR ST RT 3 TO BELFAIR, L ST RT 300/ NORTH SHORE RD, R ON BELFAIR
TAHUYA R ON HA N R ON RANCH ROAD TO SITE ADDRESS
ON LET IDE, SHA E DRIVEWAY WITH 201
General Information Construction&Occupancy Irimmakiork f Square Footage Information
No. of Bedrooms: 3 Type of Cons .: B
Type of Use: SF Insp.Area: No. of Bathrooms: 2 Occ. Grou 31_1 L Sot Size: Deck:
Type of Work: NEW Fire Dist.: No. of Stories: 1 Occ. ad: Building:1, Garage-Attached 748
Valuation: $ 190.264.91 Building Height: c. Ata s: ima Basement: COV PORC 66
Manufactured Home Inf rmatio ack Inf rma ion Shoreline& Planning Information
Make: Lengt Ft. U2.
0.0 t. S eIine: Ft. Water Body:
Re6.0 Slope: Ft. SEPA?:
Model: Widt Ft. Shoreline Desig.: Not Applicable
Side7.0 Ft.
Year: Serial No: Side 6.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtur Mechanical Fixtures FEES
Type Qt . Type Qty. Type By Date Amount Receipt
Water Closets (Toilets) 2 Furnace<100K 1 Plan Check Fee GMM 8/20/2010 $926.22 S120100001
Lavatories Heat Pump 1 Planning Review Fee GMM 8/20/2010 $205.00 S12010000i
Bath Tubs 2 Ventilation Fan 3 Fire Warden Review GMM 8/20/2010 $73.00 S12010000(
Showers 1 Exhaust Hood 1 EH Plan Review KKK 8/20/2010 $iO3.00 S62010000i
Water Heaters 1 Dryer Vent 1 Water Adequacy Plan Review KKK 8/20/2010 $103.00 S62010000i
Clothes Washer 1 Building State Fee DLC 9/3/2010 $4.50 S12011000i
Kitchen Sink 1 Building Permit Fee DLC 9/3/2010 $1,503.35 S12011000i
Dishwasher 1 Plumbing Permit Fee DLC 9/3/2010 $110.60 S120110001
Hosebibs 2 Plumbing Base Fee DLC 9/3/2010 $24.70 S120110001
Mechanical Permit Fee DLC 9/3/2010 $85.70 S12011000i
Mechanical Base Fee DLC 9/3/2010 $28.50 S12011000i
ADJUST--Plan Check Fee DLC 9/3/2010 $50.96 S120110001
Total $3,218.53
BLD2010-00740 Please refer to the following pages for conditions of this permit. Page 1 of 4
CASE NOTES FOR
BLD2010-00740
CONDITIONS FOR
BLD2010-00740
1) A Road Access Permit or Approval must be granted by the Mason County Department of Public Works. For more information contact Public Works, at
(360)427-9670, ext. 450. The building permit will not be"finaled" until the permit holder can show proof that the access permit from Public Works has
d.
2) 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- 982. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to WA state law.
X
3) 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
Dnt prior to any further inspections being performed or approvals granted.
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4) O er TA,9ent 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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5) 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
X mZ approved documents will result in failure of required building inspections.
6) 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
Buildr
partment prior to any further inspections being performed or approvals granted.
X
7) Washington State Energy Code Compliance has been approved using the following:
Heat Type: Electric or other fuels, Compliance Method: Prescriptive option IV, Window(Max U-Factor):0.35, Skylight(Max U-Factor):0.58, Doors
(Type/Max U-Factor):0.20 or less, Wall insulation R-21, Floor insulation R-30, Ceiling Insulation R-38.
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BLD2010-00740 Please refer to the following pages for conditions of this permit. Page 2 of 4
8)- WIND LOADS- Roof coverings shall be designed and tested to withstand the maximum basic wind speed. The basic wind speed for Mason County is 85
MPH.
)
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9) REQUIREMENTS FOR ROOF COVERINGS. Roof coverings shall be applied in accordance with the applicable provisions of the current code and the
manufacturer's installation instructions.
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10) 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 consult with the septic design professional involved with the project. By calling for a final
inspection of the building permit the owner/agent/co rac is acknowledging that all components of the stormwater management system have been
installed as approved on the stormwater site plan. X
11) 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 r 9n.
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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 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 projec .
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13) All changes to "approved" building plans that effect compliance with the international codes as amended and adopted, or any other Mason County
ordinanc'�lation, must be reviewed and approved by Mason County prior to construction.
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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
Inspecto be made prior to requesting additional inspections.
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BLD2010-00740 Please refer to the following pages for conditions of this permit. Page 3 of 4
15) All property lines shall be clearly identified at the time of foundation inspection. X
16) 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 my ordinances and building regulations.
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17) 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 vented action from being taken. No more than one extension may be granted.
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18) Retaining walls needed to support a su such as structures, roads, or to support slopes, shall require a separate building permit and approval prior
to construction of the retaining wall.X rc
19) Owner/,Agen is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
20) Apwoved per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure.
21) Temporary erosion control measures must be implemented to prevent water quality 01 gradation of adjacent waters or properties. Silt fencing must be
installed and maintained until upland vegetation has become established. X (��-
This permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended for a period of 180 days at any
time after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be
occupied. Proof of continuation of work is by means of a progress inspection.The owner or the agent on the owners behalf, represents that the information provided is accurate
and grants employees of Ma on County access to the above described property and structure for review and inspection.
OWNER OR AGENT: DATE: —
BLD2010-00740 Please refer to the following pages for conditions of this permit. Page 4 of 4
o CONCRETE MECHANICALMANUFACTURED HOME
p Date t3y
Footings 1 Setbacks Gas PipingRibbons
o Interior Date By Interior-Date By Dais By
o ExteriDrOate By Exterior-Date By set-up
Pain[toad t Isolated Footings INSULA 1ON Date �
BD!SLAB INSULATION Vote,
Date By Data Sy FIRE DEPARTMENT
Foundation Watts
Floors Dale By
Date By Data BY DECKS
FRAMING Watts Date By
Date By Data LAY PROPANE TANKS
PLUMBING Vault Data, g v
Data v OTHER
Ground*** Attic
Date B Date BY Type;
r _ - Date By
0.1At.V DRYWALL Type:
Date B Int.Brace Wall Date gy,
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FINAL INSPECTION
2 Water Line Fire Seperation.
2 pate gy Date By Data BY
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Puss or Request Inspect..
Type of Insp. Pail Cafe Date Cone By Comments
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o Footings 1 Setbacks Gas Piping'/4 By t4� Ribbons 0
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o Extenor Date/e �// By Exterior-Date By
Set-up _
Point Load J Isolated Footings INSULATION Date By M
BG 1 SLAB INSULATION --- ----
Date By Data y
FIRE DEPARTMENT -i
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Foundation Walls Floors Date By 3
Date /-�Gr'—�! By Data By DECKS
FRAMING Walls Date By
Date By Data sr By rq PROPANE TANKS
PLUMBING vault 1 Date By
Date ay OTHER
Groundwork Attic
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Date By Date ..M.. By Date By
aw.v DRYWALL Type-
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Permit# MASON COUNTY
BUILDING 111 426 W. CEDAR
SHELTON, WASHINGTON 98584
(360) 427-9670
CORRECTION NOTICE
Job Location c I
This structure has been inspected by Mason County Building Department
and the following VIOLATION of County Laws and Ordinances has been
found' (1 Items listed below ust a corrected to gaincompliance i / t
v_ 1
InT J . Ip,a C�hPt-
It,
4N J[ A[ C_ l/C t iv
l a V C !Ih 1rr dt' c'. - M�e.AlS
dv i SSA ct A O tdJ<
f a j t c' G=-L
Gl a
06 e- 4t
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"
❑This is not a complete inspection disasters.This is NOT
Date /2 / _ / Department 't (4, CORRECTION NOTICE.
Inspector L�
n* w, Nt7T , I rll L zllir , T F; T, -* mv
Nam 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:
httpHwww.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)-,X-,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/drainfield 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 adde 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 acknowI d a that the information provided is accurate and employees of Mason County are granted access to the above-
d roperty for review and inspection as may be required.
Owner/Agent/Contractor(circle one)Date:
Page 2 of 2
I
Name c,Y L Parcel# �;k! t5AR —3y . '1 0020 BLD#
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.linpertrous 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
X perimeter of the farthest projections(example:
�O 1 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
X _ above table
Patios/Walks X =
X = Any paved, gravel or packed area per definition
X _ above table
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 orderor 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:
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
i
MASON COUNTY PERMIT NOINA2610
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
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner iz 5 Company Name
Mailing Address V,Q Mailing Address
City State lbfi- Zip Code 5 City tate Zip ode
Phone 3 t�C? �75-?,,�'��f Other Ph. 3c�o-X(`i i 3 3`2 Phone th r P
L4wV-T44*iotder Contractor Reg.# Ex .
E-MaLaciLliess E Mail Address
Dxiuexsl 4 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, 1;_ 3:LG — 3 LA — "L 0 o 'T0 Fire District 6&
Legal Description
Site Address(Please include street name,street number and city)
Directions to site rrv\ 1,OL A):
Will timber be cut and sold in parcel preparation?Yes No
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?Ye -op
TYPE OF JOB - New X Add Alt Repair Other PRIMARY RESIDENCE 1�4 SEASONAL
� ❑
Use of Building � Describe Work
No. of Bedrooms 2 No. of Bathrooms_.2 Square Footage- 1st Floor 2nd Floor
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached Detached Carport Attached Detached
ANUF TURED HO INFORMATI -Make Model Year
L ngth Width S rial No. No. o edr oms / N of B r mQ s
T e of eat urchase rice$ placeme ? Yes/ ��
Ins II r Name Certification No.
OWNER/BUILDER Acknowledges submi n 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 parry 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 employees of Mason County access to the above described property and structure for review and inspection.
PR TI_N OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
X �. Date- 0
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Lkj Date B o10-Z610
DEPARTMENTAL REVIEW PROVED DENI D NOTES
Building Department
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
BuildingPermit Fee O $ Site Inspection
Plan Review Fee 5� EH Review Fee
Plumbing & Base Fee �y 70 f //O Gd Planning Review Fee
Mechanical & Base fee 7" Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee J6 Pre-Paid at Submittal
Valuation$ / (o / TOTAL FEES
MASON COUNTY PERMIT NO LiyIo m-1q
PLUMBING/MECHANICAL 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
APPLICANT INFORMATION CONTRACTOR INFORMATION
• Owner '2)1`� " r. Company Name
Mailing Addres _ Mailing Address
City 6c,\ 1 _ Statet #- Zip Code City tat Zip Code
`Phone 4(C - X)5 � % Other Ph. :(,-a c}I t33 Phone Other Ph.
Lien/Title Holder Contractor Reg. —Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# U DOB
SEPTIC INFORMATION - Connect to New Septic_ Existing Septic Connect to Sewer System
Name of Sewer System
° PARCEL INFORMATION - 12 Digit Parcel No. `'I Fire District
Legal Description
Site Address (Please include street name, street number and city) 3 11
Directions to site "c!h" 9'C's v.c\ . 0 t 3 c, s c,
Is property within 200'of Saltwater. Lake - %} River/Creek -Pond d1d
Wetland Seasonal Runoff ,,`i, Stream L!E" Slopes or Bluffs 15% 1�c�
TYPE OF JOB - New A_Add Alt Repair Other Use of Building
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_ Natural Gas Heat Pump-
Toilets Type of Unit No. of Units Fees
Bathroom Sink Furnace 1
Bath Tubs ` Heatpumps d
Showers t Spot Vent Fan _
Water Heater I Propane Tank
Clothes Washer i Gas Outlets
Kithen Sinks I Wood/Gas/Pellet Stove
Dishwasher I Kitchen Exhaust Hood I
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
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 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 employees of Mason County access to the above described property and structure for review and inspection.
�.PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.
1� - "—G, /O Date:
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
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