This checklist MUST be complete. ***A completed ......If project is in a flood hazard area, the...

APPLICANT INFORMATION (please print clearly)

Name of Applicant:__________________________________________________________

Site Address:_______________________________________________________________

This checklist MUST be complete.

***A completed document must be present at submittal. ***

******Incomplete applications will NOT be accepted******

PERMIT APPLICATION Applicant Verified N/A Provide a completed and signed (by owner or authorized representative)

application and applicable fees are due at submittal.

Provide a completed plumbing and Mechanical Application

SITE PLAN Provide one (1) copy of proposed site plan. Drawn to scale of either

1” = 10’ or 1” = 20’ depending on lot size.

North Arrow, location and dimensions of all property lines and easements.

Vicinity map showing location and names of all roads and easements. (public and

private)

Show distances to all structures, septic tanks, drain fields, property lines, top of

slopes or cuts and easements.

Zoning (indicate):

Rural Residential: 2.5 5 10 20 Other:

Urban Growth Area: Zone:

Front yard: Direction:

Rear yard: Direction:

Side yard: Direction:

Side yard: Direction:

All access points, width of access. (easements and driveways).

Contour lines in twenty (20) foot increments. See Parcel Map Viewer on website

Building height shown on elevations views.

Floodplain boundaries and setback distances. See Plans for additional

requirements.

Wetland or surface water (if any) and any applicable buffers. If yes, a wetland

report may need to be submitted.

Is the site near a Shoreline (stream, creek, lake, saltwater) if yes, please indicate?

Name of shoreline:

Shoreline designation:

Stream type (F, S, Ns, Np):

Is the proposed site within 300 feet of a slope 15% of greater? If yes, a geological

report or assessment may be required.

Existing/proposed on-site septic system and reserve areas, providing setback to

structures.

Existing/proposed wells (show 100 ft well radius, with distances to structures).

Existing and proposed stormwater controls (downspouts, dry wells, etc.)

Exterior storage tanks (propane) and HVAC equipment.

BLD

_______-_________

RCVD BY:

DATE STAMP

PLANS Applicant Verified N/A Provide three (3) copies of plans (2 full size min. 18”x 24” and 1 small size) and

two (2) copies of all specifications and engineering. Plans must be drawn to scale

of ¼” = 1’. All notations and drawings must be clear and legible. All Engineering

call-outs must be detailed on plans.

Engineered plans must provide calculations/analysis. Analysis must include the

following information:

2015 International Building Code

Snow load (by location)

Seismic zone (D-2)

Exposure (by location and topography)

Wind speed (85 MPH basic and 110 ultimate w/ 3 second gust)

If project is in a flood hazard area, the submittal MUST include an Elevation

Certificate, flood venting compliance and an elevation detail indicating the location

of finished floor relative to the Base Flood Elevation or Design Flood Elevation as

designated by surveyor or engineer.

FOUNDATION PLAN Plan view of foundation/footings/pads

Type, size and location of footing (stepped foundation provide detail)

Elevation view of foundation steps, with final grade

Cross-sections of footing and foundation (including height of wall).

Floor joist and spacing (each floor).

Show location of flood venting and detail the method and compliance for venting.

Type and locations of hold-downs and anchors.

Crawl access location and size.

Insulation value for foundation (if slab or basement). See Energy Credits for

additional requirements, credits must be indicated on the plans.

If project is in Flood Hazard Area provide flood venting compliance including vent

locations, vent type, elevation detail for venting location interior and exterior of the

crawl space.

FLOOR PLAN Square-footage of each floor

Use of each room

Location and size of attic access

Dimensions of building and rooms.

Location and type of furnaces, water heaters, smoke detectors, and carbon

monoxide detectors. Include location of bollard for appliances located in garage.

Plumbing fixture locations

Location of doors, windows (include size, egress, tempered and skylights)

Insulation value in floor. See Energy Credits for additional requirements, must be

indicated on the plans.

Location of ventilation fans and CFM for each.

Location of whole house fan and CFM (continuous or intermittent)

Location, side and type of brace wall or shear-wall panels. If structure is

engineered, must supply two copies of required analysis (calculations)

Dimensions and framing details of decks (including joists, beams, posts, ledgers.

Plan MUST include size, grade, spacing, length and species or type of material)

Dimensions and framing details of stairs. Plan MUST include size, material,

spacing, length.

ELEVATIONS AND WALL DETAILS Typical and rated walls details (garage separation)

Listing of fire-resistive wall designs (duplex or townhouse)

Building elevations- all 4 sides Show distance from grade at each corner.

Exterior wall details when distance between overhangs is less than 5 feet.

Insulation value for walls. See Energy Credits for additional requirements, must be

indicated on the plans.

If project is in floodplain must provide Elevation detail indicating the location of

finished floor relative to the Base Flood Elevation or Design Flood Elevation as

designated by surveyor or engineer.

ROOF PLAN Layout of roof system

Label type of roof system, rafters, engineered trusses & spacing

Headers noted at each location or typical header noted.

Roof pitch and covering materials

Sheathing types, dimensions and fastening

Attic venting (type, location and amount)

Insulation value for roof (R38 vault and R49 ceiling) See Energy Credits for

addition requirements, must be indicated on the plans.

ENERGY CODE REQUIREMENTS Applicant Verified N/A Completed Washington State Energy Code form

Plans must indicate fuel source for furnaces, water heaters and other appliances.

Completed Heating/Cooling system size worksheet.

Compliance to the Washington State Energy Code and required Credits.

Construction drawings/plans MUST include all credit information on the plan

details such as insulation, ventilation, furnaces, windows etc. Plans must also

include the amount of credits and which credits are chosen.

I verify that all required documents, plans and specification associated with this application have been submitted and are

accurate. If information, details are not provide the application will be place on HOLD until all required details are

provided and accurate.

________________________________________ ______________________________________ ____________

Signature of owner or authorized agent Print Name Date

MASON COUNTY COMMUNITY SERVICES PERMIT ASSISTANCE CENTER: BUILDING PLANNING PUBLIC HEALTH FIRE MARSHAL

615 W. Alder Street, Shelton, WA 98584

Phone Shelton: (360)427-9670 ext. 352 • Fax: (360)427-7798 Phone Belfair: (360)275-4467 • Phone Elma: (360)482-5269

BUILDING PERMIT APPLICATION

PROPERTY OWNER INFORMATION:

NAME:_______________________________________

MAILING ADDRESS:___________________________

CITY:_______________ STATE:______ ZIP:________

PHONE #1:____________________________________

PHONE #2:____________________________________

EMAIL:_______________________________________

PARCEL INFORMATION:

PARCEL NUMBER (12 Digit Number) _______________________________________ ZONING____________________

LEGAL DESCRIPTION (Abbreviated) _______________________________________ FIRE DISTRICT_______________

SITE ADDRESS_____________________________________________________CITY___________________________

DIRECTIONS TO SITE ADDRESS ____________________________________________________________________________

__________________________________________________________________________________________________________

IS THE PROJECT WITHIN 300 FT OF SLOPE(S) GREATER THAN 14%: YES⎕ NO ⎕ SNOW LOAD:_______psf IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply): SALTWATER ⎕ LAKE ⎕ RIVER/CREEK ⎕ POND ⎕ WETLAND ⎕ SEASONAL RUNOFF ⎕ STREAM ⎕

TYPE OF WORK: NEW ⎕ ADDITION ⎕ ALTERATION ⎕ REPAIR ⎕ OTHER ⎕_______________________

USE OF STRUCTURE (Residence, Garage, Commercial Bldg, Etc.)__________________________________________________________

IS USE: PRIMARY ⎕ SEASONAL ⎕ NUMBER OF BEDROOMS_________ NUMBER OF BATHROOMS_______

HEATED STRUCTURE? YES (Whole Bldg) ⎕ YES (Part[s] of Bldg) ⎕ NO ⎕

DESCRIBE WORK__________________________________________________________________________________________

SQUARE FOOTAGE: (proposed)

1ST FLOOR________ sq. ft. 2ND FLOOR________ sq. ft. 3RD FLOOR________ sq. ft. BASEMENT________ sq. ft.

DECK________ sq. ft. COVERED DECK________ sq. ft. STORAGE__________ sq. ft. OTHER________ sq. ft.

GARAGE________ sq. ft. Attached ⎕ Detached ⎕ CARPORT__________ sq. ft. Attached ⎕ Detached ⎕

OWNER 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 and I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or legal representative, represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for review and inspection. This permit/application becomes null & void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days.

PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON

COUNTY CODE 14.08.42)

X_____________________________________________ _________________________________ Signature of OWNER (Must be signed by the OWNER) Date

MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*

MAKE___________________________ MODEL_______________________ YEAR______________ LENGTH_____________

WIDTH___________ BEDROOMS____________ BATHS______________ SERIAL NUMBER________________________

CONTRACTOR INFORMATION:

NAME:_________________________________________

MAILING ADDRESS:_____________________________

CITY:_______________ STATE:______ ZIP:_________

PHONE:________________ CELL: _________________

EMAIL :________________________________________

L&I REG #______________________ EXP. ___/___/___

DEPARTMENTAL REVIEW APPROVED

D

DATE DENIED DATE TAGS/NOTES/CONDITIONS

BUILDING DEPARTMENT

PLANNING DEPARTMENT

FIRE MARSHAL

Permit No:___________________

PUBLIC HEALTH

ENVIRONMENTAL HEALTH:

SEWAGE/SEWER SOURCE: SEPTIC ⎕ SEWER ⎕ / NEW ⎕ EXISTING ⎕

PLUMBING IN STRUCTURE? YES ⎕ NO ⎕ If yes, attach completed Water Adequacy Form

PERIMETER/FOUNDATION DRAINS PROPOSED? YES ⎕ NO⎕ EXISTING SQ. FT. _________________

EXISTING BEDROOMS __________ PROPOSED BEDROOMS __________ TOTAL BEDROOMS __________

PRIMARY CONTACT: OWNER ⎕ CONTRACTOR ⎕ OTHER ⎕ NAME ______________________________________________________________________ EMAIL ________________________________________________________ MAILING ADDRESS _______________________________________________________ CITY ______________________ STATE __________ ZIP____________ PHONE ______________________________________________ CELL _______________________________________________________

http://www.co.mason.wa.us/community_dev/

Rev: 1/27/2016 JBN

MASON COUNTY COMMUNITY SERVICES PERMIT ASSISTANCE CENTER:

BUILDING PLANNING FIRE MARSHAL

615 W. Alder St - Shelton, WA 98584

www.co.mason.wa.us

Phone Shelton: (360)427-9670 ext. 352 • Fax: (360)427-7798 Phone Belfair: (360)275-4467 • Phone Elma: (360)482-5269

PLUMBING & MECHANICAL PERMIT APPLICATION

OWNER INFORMATION: NAME:_______________________________________

MAILING ADDRESS:__________________________

CITY:______________ STATE:_______ ZIP:________

1st PHONE:____________________________________

2nd PHONE:___________________________________

EMAIL:_______________________________________

PARCEL INFORMATION: PARCEL NUMBER (12 Digit Number):_________________________________________ Zoning:__________________

LEGAL DESCRIPTION (Abbreviated):_________________________________________________________________

SITE ADDRESS:______________________________________________________CITY:______________________

DIRECTIONS TO SITE ADDRESS:__________________________________________________________________

________________________________________________________________________________________________

TYPE OF JOB: NEW ______ ADD______ ALT______ REPAIR______ OTHER______ USE OF BUILDING______________________________

LOCATION OF FIXTURES/UNITS – 1ST FLOOR_____ 2ND FLOOR______BASEMENT _____ GARAGE____ OTHER_______

OWNER acknowledge 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 contractor. I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for review and inspection. This permit/application becomes null & void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OFTHIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.

X__________________________________________ ____________________________________ Signature of Owner Date

CONTRACTOR INFORMATION: NAME:_________________________________________

MAILING ADDRESS:_____________________________

CITY:____________ STATE:_________ ZIP:_________

PHONE:________________ CELL: _________________

EMAIL :________________________________________

L&I REG #_____________________ EXP. ___/___/___

DEPARTMENTAL REVIEW

APPROVED

DATE

DENIED DATE

TAGS/NOTES/CONDITIONS

BUILDING DEPARTMENT

PLANNING DEPARTMENT

FIRE MARSHAL

PLUMBING FIXTURES (SHOW NUMBER OF EACH)

Type of Fixture No. of Fixtures Fees

Toilets ____________ ___________

Bathroom Sink ____________ ___________

Bath Tubs ____________ ___________

Showers ____________ ___________

Water Heater ____________ ___________

Clothes Washer ____________ ___________

Kitchen Sinks ____________ ___________

Dishwasher ____________ ___________

Hose bibs ____________ ___________

Other ____________ ___________

Base Fee ___________ TOTAL PLUMBING ___________

MECHANICAL UNITS Fuel Type:Electric____LPG____Natural Gas____Ductless___

Type of Unit No. of Units Fees

Furnace _________ ___________

Heat Pump _________ ___________

Spot Vent Fan _________ ___________

Propane Tank _________ ___________

Gas Outlets _________ ___________

Wood/Gas/Pellet Stove _________ ___________

Kitchen Exhaust Hood _________ ___________

Dryer Vent _________ ___________

Solar Panel _________ ___________

Other _________ ___________

Base Fee ___________ TOTAL MECHANICAL ___________

Permit No:________________

http://www.co.mason.wa.us/community_dev/

www.co.mason.wa.us

MASON COUNTY DEPARTMENT OF COMMUNITY SERVICES

SITE PLAN INSTRUCTIONS A complete, accurate, and detailed site plan is important to avoid delays in the review and approval of your pro-ject. A sample site plan and topography are located on the inside of this form. An easy to use grid, which can be used to draw your site plan on, is also located inside. The following items will be required, if applicable, to complete the building permit application package. Additional information may be needed depending upon individual site conditions. For more information see submittal standards and instructions on the back of this form.

Building Permit Application Form

Site Plan 1 1 1 1 1 1 1 1 4

Septic Records

Septic Permit Application & Septic Design 3

Water Adequacy Form

Construction Plans 3 3 3 3 3 3

Energy Code Application Form If

Heated

Septic Pumpers Report Existing systems older than 3 years.

Property Lines Flagged

Geotechnical Study See instructions on back 3 3 3 3 3 3 3 3

Plumbing/Mechanical Application Form

Engineered Calculations

2 2 2 2 2 2

Floor Plan

SEPA

Road Access Permit

Fire Apparatus Access Road

Small Parcel Stormwater Application/Worksheet

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Submittal Requirements

The number in the table indicates the number of copies required if applicable.

Required for submittal of a complete application.

A pumpers report may be required when a septic system is existing and has been installed for three or more years. The report,

dated within the last three years, shall include the size and condition of both tank and baffles.

Additional information and permits may be required by the Planning Dept. call extension 352 for information.

If applicable, needed when site conditions require additional information.

Engineered plans shall have design information & details transferred onto plans. One copy of the plans and calculations shall be

wet-stamped. Revised 09/04/2013

SITE PLAN REQUIREMENTS:

A complete, accurate and detailed site plan is important to avoid delays in the review and approval of your project. Use the checklist below as a tool to help you complete the site plan.

q 1. Scale: A scale of 1”=20’, is typical but other scales such as 1”=10’ or 1”-40’ are also

acceptable. Do not exceed 1”=60.

q 2. North arrow

q 3. Property line location and dimensions.

q 4. Label abutting streets

q 5. Shoreline/Surface water: Indicate creeks, streams, lakes, ponds, wetlands and

other bodies of water within 300 ft of the proposed project.

q 6. Wetlands and Seasonal Drainage: Show setback distances from wetlands or

seasonal drainage.

q 7. Easements: Indicate location and size of road, utility, and private easements.

q 8. Show All Existing Development: Identify existing and proposed structures.

Include porches, decks, roof overhangs, cantilevers, and structures that will be demolished.

q 9. Proposed Building Footprint: Use scale to show distances to property lines,

existing structures, septic tank and drainfield. Stake or flag footprint of proposed structure.

q 10. Sewage Disposal System: Identify septic tank location and drainfield.

q 11. Existing and proposed Buffers: Include open space, fences, sidewalks and

parking areas.

q 12. Retaining walls: Proposed and existing.

q 13. Slopes/Site contours (Topography): Identify any slopes greater than 15%, fills

or cuts greater than 4ft. that are located within 300ft. of the proposed project. Use Contour lines or arrows to show the direction of the slope.

q 14. Wells: Show existing and proposed, need to include all wells located within 100 ft of

property.

q 15. Waterfront projects: Show all structures on adjacent property.

q 16. Driveway/ Site Access

A. Site Plan: Site plans must be drawn to scale . On at least 8 ½” x 11” paper. A checklist indicating information required on the site plan is listed in the site plan application. Incomplete site plans will not be accepted.

B. Construction Plans: Plans must be drawn to scale, preferably ¼” = 1’. Dimensions must be noted on the plans. A complete set of plans shall include foundation plan, framing plans, floor plans, cross sections, and elevations. A complete building plan will give the building department enough information on how your project will be constructed. If you plan to construct a log home, pole building greater than 864 square feet, or a metal structure, calculations stamped by a Washington State licensed engineer or architect, will be required. Also, masonry or concrete structures, may require an engineered design. The building official may require additional drawings, details, sections, or stamped-engineered calculations and/or details.

C. Directions to Site: Provide accurate directions to your project site. This information will be used by staff when they review the project and by building inspectors.

D. Structural Engineered Calculations: Will be required if the proposed structure does not meet conventional construction standards. Include 2 sets with your building permit application.

E. Road Access Permit: May be required if accessing a public road or right of way. Contact Mason County Public Works for county maintained roads at (360) 427-9670, ext. 450 for more information. For state highways contact Washington State Department of Transportation at (360) 874-3050.

F. Washington State Energy Code and Ventilation & Indoor Air Quality Code (WSEC & VIAQ): Refers to energy envelope calculations and air quality code compliance.

G. Existing On-Site Septic System: Documentation of an approved on-site sewage system will be required. An existing system must have records and a pumpers report, dated within the last three years, per Mason County Health Services Policies. These policies are case/job specific if you have any questions please contact Environmental Health at (360) 427-9670 ext. 352.

H. Septic Approval or Sewer Permit: A Septic design application must be approved by the Mason County Environmental Health Department prior to permit issuance for all single family developments using septic systems. If sewer is available, sewer permits can be obtained by calling Mason County Utilities at (360) 427-9670 ext. 296.

I. Water Availability: The local water purveyor must complete a water availability application if the project will be connected to a public water system. Private well systems require a water well report, or capacity test, and bacteriological test dated within the previous 12 month period.

J. Site Pre-Inspection: Resource lands and critical areas checklist. Includes a site visit by a planner to identify critical areas on a site.

K. Aquifer Recharge Areas: Areas where water infiltrates the soil to the groundwater table. Call Planning Department, extension 352.

L. Critical Area: Critical areas include shorelines, flood plains, streams, wetlands, important wildlife habitat areas and landslide hazard areas (such as steep slopes and marine bluffs). The planner may need to visit your site to decide whether a buffer zone is required between the critical area and the proposed structures. Please mark the corners of proposed structure(s) with flags or stakes.

M. Geotechnical Study: A geotechnical assessment or report will be required if the parcel is located within a Landslide/Erosion Hazard Area.

N. Wetland: Areas that are inundated or saturated by surface water or ground water at a frequency and duration sufficient to support, under normal circumstances, a prevalence of vegetation typically adapted for life in saturated soil conditions. Wetlands generally include swamps, marshes, bogs, and similar areas.

O. Buffer: An area of land or designated for the purpose of insulating or separating a structure or land use from a critical area or resource land in such a manner as to reduce or mitigate any adverse impacts of the developed area.

P. Parcel Number: a 12-digit tax assessment number assigned to each parcel by the Assessor’s Office.

Q. Legal Description: This describes the parcel of land identified by the 12-digit tax identification number. It is acceptable to submit a brief legal description of the parcel as it appears on record at the Assessor’s office. Legal descriptions are used to check the dimensions of a parcel and any underlying restrictions such as setbacks from property lines or easements, lot coverage, or height of buildings.

R. Address: Site addresses are assigned through the Mason County Department of Community Development, for more information (360)427-9670 ext. 291.

S. Contractor Registration Number: Contractors must be licensed with the state. The contractor license number can be obtained from the general contractor that will be performing the work or through the Labor & Industries website at: www.lni.wa.gov/contractors.

An owner can be an owner-contractor when building on his or her own property.

T. SEPA: The State Environmental Policy Act, RCW 43.21C and implementing State and County administrative rules.

U. Fire Apparatus Access Road: Mason County Standards require a fire apparatus access road for every facility, building, or portion of a building that is more than 150 feet from an existing approved access road. When the new fire apparatus road is installed, it is to extend to within 150 feet of any portion of the exterior walls of any building. Fire apparatus Access Roads Ordinance and details are available. To request a copy call (360) 427-9670 ext. 352

SUBMITTAL STANDARD INSTRUCTIONS/INFORMATION

Distances from property lines should be measured from the ‘Furthest Projection ‘

The ‘Furthest Projection’ may be an eave, gutter, land, 2nd level deck, heat pump, or propane tank.

X = distance or setback (in feet) between property line and ‘Furthest Projection’. Contact a Permit Technician if you have questions or require clarification.

‘Furthest Projection’

Property Line

‘X’

Heat Pump

House with cantilevered 2nd level, heat pump, 2’ eave, and gutter. In this case, the gutter would be the ‘Furthest Projection’.

Setback Instructions

Sample Site Plan and Topography 1”=40’ scale

Wetland

Stormwater run-off path

Allowable Building Area

95’

40’

125’ 171’

80’

56’

20’

6’

114’

104’

Main Street

Sample Site Plan and Topography Scale: 1” = 40’

1

MASON COUNTY DEPARTMENT OF COMMUNITY SERVICES

BUILDING DIVISION

SHELTON (360) 427-9670 BELFAIR (360) 275-4467 Elma (360) 482-5269 FAX: (360) 427-7798 WEB SITE: www.co.mason.wa.us

615 W ALDER STREET, SHELTON 98584

2015 International Energy Conservation Code, as amended by WAC 51-11 (IECC) Effective July 1, 2016.

Ventilation code provisions are located in the 2015 International Residential Code (IRC), 2015 International Mechanical Code (IMC), & 2015 International Building Code

A complete energy code application form will include information that clearly identifies compliance methods for heat sizing, thermal envelope, and whole-house ventilation. This form includes compliance instructions and information needed. Energy code compliance information, forms, worksheets, and educational information is also available on the Washington State University Extension Energy Program (WSU-EP) website. To access the website go to http://www.energy.wsu.edu/BuildingEfficiency/EnergyCode.aspx .

The website includes a heat system sizing calculator. Submit a completed heat sizing calculator worksheet when the building permit is submitted. In addition to the heat sizing calculator the website has helpful compliance information and worksheets for prescriptive and component performance options along with a glazing schedule.

INSTRUCTIONS: Complete the Mason County Energy Code application and submit with a heat sizing calculator available on the WSU-EP website, see item # 4 below:

1 Identify the compliance method. The most common and simplest approach is the prescriptive method for energy code compliance. See prescriptive table R402.1.1 located in the instructions. The Performance Alternative approach referenced in IECC Section R405 may also be used for energy code compliance. For more information contact Mason County Building Department staff at (360) 427-9670 ext. 352 or WSU Energy Program at (360) 956-2042. Compliance must be shown on your construction drawing in addition to this application.

2 Identify the whole-house ventilation compliance method. A ventilation system must be installed in accordance with The International Residential Code, Section M1507. The most common ventilation methods include a whole-house ventilation system using exhaust fans (M1507.3.4) and a whole-house ventilation system integrated with a forced-air system (M1507.3.5). Other ventilation systems include whole-house ventilation system using a supply fan (M1507.3.6) and whole-house ventilation system using a heat-recovery ventilation system (M1507.3.7). Ventilation openings are required in each habitable room in accordance with M1507.3.4.4. If you need additional information we recommend that you discuss with your heating and ventilation system professional. In addition Mason County staff will be happy to discuss the options if you are not sure which compliance option will work for you.

3 Identify the Additional Energy Efficiency Requirements listed in Table R406.2. The drawings included with the building permit application must show and identify which options have been selected and the point value of each option. Each one and two-family dwelling unit and townhouses are required to achieve the following minimum number of credits:

a) Small dwelling units: less than 1500 sq. feet of heated or cooled floor area and less than 300 sq. ft fenestration area (skylights, doors, windows, etc). Additions to existing building that are greater than 500 sq. ft. of heated floor but less than 1500 sq ft of area. Requires 1.5 credits

b) Medium dwelling units that are not included in (a) above {small dwelling}, OR (c) below {large dwelling} Requires 3.5 credits

EXCEPTION: Dwelling units serving R-2 occupancies shall require. Requires 2.5 credits.

http://www.co.mason.wa.us/

http://www.energy.wsu.edu/BuildingEfficiency/EnergyCode.aspx

2

(R-2 occupancy is Residential occupancies containing sleeping units or more than two dwelling units where the occupants are primarily permanent in nature, including: Apartment houses, Boarding houses (non-transient) with more than 16 occupants, Congregate living facilities (non-transient) with more than 16 occupants, Convents, Dormitories, Fraternities and sororities, Hotels (non-transient), Live/work units, Monasteries, Motels (non-transient), Vacation timeshare properties.)

c) Large dwelling unit is a dwelling unit that exceeds 5,000 sq. ft. of heated or cooled floor area. Requires 4.5 credits.

d) Additions less than 500 sq feet. Requires .5 credits

4 Must provide a completed heating/cooling system size worksheet to verify compliance to IECC R403.7. The calculator/worksheet is available on the WSU-Energy Program website at: http://www.energy.wsu.edu/Documents/Heat_Sizing_code%20specs_final_2015.xls. Staff may be able to assist with preparation of the worksheet.

5 Must meet the prescriptive option for all fenestration products. Products shall comply with the required U-factor listed in Table R402.1.3. Windows, doors, and glazed doors shall have a tested U-factor or .30 or less. When using the small dwelling option for energy credits (a) or Performance Alternative approach you must provide a fenestration schedule that identifies the square feet and U-factor of each item. Fenestration is defined in the IECC as skylights, roof windows, vertical windows, opaque doors, glazed-doors that include products with glass and non-glass glazing materials.

6 Identify on the construction drawings the location and fuel type of the heating system, water heater, location of exhaust fans (bathroom, laundry, kitchen, etc.) and R-factor of proposed insulation for walls, floors, ceilings, and concrete slab floors on the building plans.

7 Not less than 75% of all permanently installed lamps in lighting fixtures shall be high efficacy lamps. High efficacy lamps are defined in IECC Chapter 2 and are considered compact fluorescent lamps, T-8 or smaller diameter linear fluorescent lamps, or lamps with a minimum efficacy 60 lumens per watt for lamps over 40 watts, 50 lumens per watt for lamps over 15 watts to 40 watts, and 40 lumens per watt for lamps 15 watts or less.

If you need assistance please contact Mason County Community Development at (360) 427-9670 ext. 352 or WSEC compliance information and code text is also available on the WSU-Energy Program website at: http://www.energy.wsu.edu/BuildingEfficiency/EnergyCode.aspx

Prescriptive Requirements 0,1 for Mason County Climate Zone 4-C, Table R402.1.1

Option

Glazing Area % of Floor

Fenestration U-factor

Ceiling

Vaulted Ceiling j

Wall Above Grade

Wall

int c,n below grade

Floor

Slab d on

Grade

Vertical

(Includes doors, windows, etc.)

Skylight

b

4C Unlimited .30 .50 R-49 R-38

R-21 int k,l

10/15/21 int + TB

R-30

R-10, 2 ft Heated slabs require R10

full slab.

n Log & solid timber wall with a min. avg. thickness of 3.5” are exempt from the above grade wall insulation requirements. All footnotes are available on WSU-Energy Program Website @ http://www.energy.wsu.edu/BuildingEfficiency/EnergyCode.aspx

http://www.energy.wsu.edu/Documents/Heat_Sizing_code%20specs_final_2015.xls



3

MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT WSEC/ Ventilation Code Compliance Application

Submit with heating/cooling system size worksheet (see instructions #4)

Owner: Parcel#: Type of project:

Total Sq. Ft. of heated area::

1st Floor : 2nd floor: Heated Basement:

Heating System Type: Electric wall heater Electric Central Furnace LPG Furnace

Heat Pump with electric furnace Heat pump with gas furnace Ductless Heat Pump Boiler, specify fuel type: ______________ Other: Specify:_____________________________________________

Compliance Method

Must Check one::

Prescriptive Option Table R402.1.1 (see table on previous page)

Component Performance, R402.1.3 – Calculation worksheets required

Other (Specify):_______________________________________

Check one Ventilation System

Whole House Ventilation system

using exhaust fans & window or wall fresh air vents (M1507.3.4). If using window vents be sure to order windows with vents.

Whole House Ventilation

Integrated with a Forced Air System (M1507.3.5)

Other, describe:___________________

____________________________________

Additional Energy

Efficiency Requirem

ents

Energy credits

required:

______

Referencing Table R406.2, “Additional Residential Energy Efficiency Requirements,” all residential units must develop credits as specified in Table 406.2. Identify and describe which option(s) will be used to comply. If the table is not attached to this form you can access the table on our website at: http://www.co.mason.wa.us/forms/Community_Dev/iecc_wsec.pdf

a) Description: Small dwelling units: less than 1,500 sq. feet of heated or cooled floor area and less than 300 sq. ft fenestration area (skylights, doors, windows, etc). *Including additions to existing building that are greater than 500 sq. ft. of heated floor but less than 1,500 sq ft of floor area. Requires 1.5 credits

b) Medium dwelling units that are not included in (a) above {small dwelling}, OR (c) below {large dwelling} Requires 3.5 credits

EXCEPTION: Dwelling units serving R-2 occupancies shall require. Requires 2.5 credits. See page two for description.

c) Large dwelling unit is a dwelling unit that exceeds 5,000 sq. ft. of heated or cooled floor area. Requires 4.5 credits

d) Additions less than 500 sq feet. Requires .5 credits

(Fenestration is defined in the IECC as skylights, roof windows, vertical windows, opaque doors, glazed-doors that include products with glass and non-glass glazing materials.)

Using Option number(s):

___________________

_

Describe Energy Credit Option(s):

http://www.co.mason.wa.us/forms/Community_Dev/iecc_wsec.pdf

4

FENESTRATION1SCHEDULE USE FOR ENERGY CREDIT, a) SMALL DWELLING OPTION & COMPONENT PERFORMANCE COMPLIANCE

List all windows, doors, skylights. (If needed, attach an additional sheet)

1Fenestration is defined in IECC Chapter 2 as skylights, roof windows, vertical windows, opaque doors, glazed-doors that include products with glass and non-glass glazing materials.

Manufacturer

Location

U-Factor

Size (rough opening)

Quantity Total Square Feet

Total Fenestration: windows, skylights and door area

Energy Credits

5

(2015 WSEC ~ Table 406.2)

OPTION DESCRIPTION CREDIT(S)

1a EFFICIENT BUILDING ENVELOPE 1a:

Prescriptive compliance is based on Table R402.1.1 with the following modifications:

Vertical fenestration U = 0.28 Floor R-38

Slab on grade R-10 perimeter and under entire slab

Below grade slab R-10 perimeter and under entire slab

or

Compliance based on Section R402.1.4: Reduce the Total UA by 5%.

0.5

1b EFFICIENT BUILDING ENVELOPE 1b:


Vertical fenestration U = 0.25

Wall R-21 plus R-4

Floor R-38 Basement wall R-21 int plus R-5 ci



or


1.0

1c EFFICIENT BUILDING ENVELOPE 1c:



Ceiling and single-rafter or joist-vaulted R-49 advanced Wood frame wall R-21 int plus R-12 ci Floor R-38

Basement wall R-21 int plus R-12 ci



or


2.0

1da

EFFICIENT BUILDING ENVELOPE 1d:



0.5

2a AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2a:

Compliance based on R402.4.1.2: Reduce the tested air leakage to 3.0 air changes per

hour maximum

and

All whole house ventilation requirements as determined by Section M1507.3 of the

International Residential Code shall be met with a high efficiency fan (maximum 0.35

watts/cfm), not interlocked with the furnace fan. Ventilation systems using a furnace

including an ECM motor are allowed, provided that they are controlled to operate at

low speed in ventilation only mode.

To qualify to claim this credit, the building permit drawings shall specify the option

being selected and shall specify the maximum tested building air leakage and shall

show the qualifying ventilation system.

0.5

2b AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2b:

Compliance based on Section R402.4.1.2: Reduce the tested air leakage to 2.0 air

changes per hour maximum

and


International Residential Code shall be met with a heat recovery ventilation system

with minimum sensible heat recovery efficiency of 0.70.



show the heat recovery ventilation system.

1.0

6


2c AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2c:

Compliance based on Section R402.4.1.2: Reduce the tested air leakage to 1.5 air

changes per hour maximum

and


International Residential Code shall be met with a heat recovery ventilation system

with minimum sensible heat recovery efficiency of 0.85.



show the heat recovery ventilation system.

1.5

3ab HIGH EFFICIENCY HVAC EQUIPMENT 3a:

Gas, propane or oil-fired furnace with minimum AFUE of 94%, or

Gas, propane or oiled-fired boiler with minimum AFUE of 92%


being selected and shall specify the heating equipment type and the minimum

equipment efficiency.

1.0

3bb HIGH EFFICIENCY HVAC EQUIPMENT 3b:

Air-source heat pump with minimum HSPF of 9.0




1.0

3cb HIGH EFFICIENCY HVAC EQUIPMENT 3c:

Closed-loop ground source heat pump; with a minimum COP of 3.3

or

Open loop water source heat pump with a maximum pumping hydraulic head of 150

feet and minimum COP of 3.6




1.5

3db HIGH EFFICIENCY HVAC EQUIPMENT 3d:

Ductless Split System Heat Pumps, Zonal Control: In homes where the primary space heating system is zonal electric heating, a ductless heat pump system shall be installed

and provide heating to the largest zone of the housing unit.




1.0

4 HIGH EFFICIENCY HVAC DISTRIBUTION SYSTEM:

All heating and cooling system components installed inside the conditioned space.

This includes all equipment and distribution system components such as forced air

ducts, hydronic piping, hydronic floor heating loop, convectors and radiators. All

combustion equipment shall be direct vent or sealed combustion.

For forced air ducts: A maximum of 10 linear feet of return ducts and 5 linear feet of

supply ducts may be located outside the conditioned space. All metallic ducts located

outside the conditioned space must have both transverse and longitudinal joints sealed

with mastic. If flex ducts are used, they cannot contain splices. Flex duct connections

must be made with nylon straps and installed using a plastic strapping tensioning tool.

Ducts located outside the conditioned space must be insulated to a minimum of R-8.

Locating system components in conditioned crawl spaces is not permitted under this

option.

Electric resistance heat and ductless heat pumps are not permitted under this option.

Direct combustion heating equipment with AFUE less than 80% is not permitted

under this option.


being selected and shall specify the heating equipment type and shall show the

location of the heating and cooling equipment and all the ductwork.

1.0

7


5a EFFICIENT WATER HEATING 5a:

All showerhead and kitchen sink faucets installed in the house shall be rated at 1.75

GPM or less. All other lavatory faucets shall be rated at 1.0 GPM or less.c


being selected and shall specify the maximum flow rates for all showerheads, kitchen

sink faucets, and other lavatory faucets.

0.5

5b EFFICIENT WATER HEATING 5b:

Water heating system shall include one of the following:

Gas, propane or oil water heater with a minimum EF of 0.74

or

Water heater heated by ground source heat pump meeting the requirements of Option

3c.

or

For R-2 occupancy, a central heat pump water heater with an EF greater than 2.0 that

would supply DHW to all the units through a central water loop insulated with R-8

minimum pipe insulation.


being selected and shall specify the water heater equipment type and the minimum


1.0

5c EFFICIENT WATER HEATING 5c:

Water heating system shall include one of the following:

Gas, propane or oil water heater with a minimum EF of 0.91

or Solar water heating supplementing a minimum standard water heater. Solar water

heating will provide a rated minimum savings of 85 therms or 2000 kWh based on the

Solar Rating and Certification Corporation (SRCC) Annual Performance of OG-300 Certified Solar Water Heating Systems

or

Electric heat pump water heater with a minimum EF of 2.0 and meeting the standards

of NEEA's Northern Climate Specifications for Heat Pump Water Heaters


being selected and shall specify the water heater equipment type and the minimum

equipment efficiency and, for solar water heating systems, the calculation of the

minimum energy savings.

1.5

5d EFFICIENT WATER HEATING 5d: A drain water heat recovery unit(s) shall be installed, which captures waste water heat

from all the showers, and has a minimum efficiency of 40% if installed for equal flow

or a minimum efficiency of 52% if installed for unequal flow. Such units shall be

rated in accordance CSA B55.1 and be so labeled.

To qualify to claim this credit, the building permit drawings shall include a plumbing

diagram that specified the drain water heat recovery units and the plumbing layout

needed to install it and labels or other documentation shall be provided that

demonstrates that the unit complies with the standard.

0.5

6 RENEWABLE ELECTRIC ENERGY:

For each 1200 kWh of electrical generation per each housing unit provided annually by on-site wind or solar equipment a 0.5 credit shall be allowed, up to 3 credits.

Generation shall be calculated as follows: For solar electric systems, the design shall be demonstrated to meet this requirement

using the National Renewable Energy Laboratory calculator PVWATTs.

Documentation noting solar access shall be included on the plans.

For wind generation projects designs shall document annual power generation based on the following factors: The wind turbine power curve; average annual wind speed at

the site; frequency distribution of the wind speed at the site and height of the tower.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall show the photovoltaic or wind turbine equipment type,

Provide documentation of solar and wind access, and include a calculation of the

minimum annual energy power production.

0.5

a. Projects using this option may not use Option 1a, 1b or 1c.

b. Projects may only include credit from one space heating option, 3a, 3b, 3c or 3d. When a housing unit has two pieces of

equipment (i.e., two furnaces) both must meet the standard to receive the credit.

c. Plumbing Fixtures Flow Ratings. Low flow plumbing fixtures (water closets and urinals) and fittings (faucets and

showerheads) shall comply with the following requirements:

1. Residential bathroom lavatory sink faucets: Maximum flow rate - 3.8 L/min (1.0 gal/min) when tested in accordance

with ASME A112.18.1/CSA B125.1.

2. Residential kitchen faucets: Maximum flow rate - 6.6 L/min (1.75 gal/min) when tested in accordance with ASME A112.18.1/CSA B125.1.

3. Residential showerheads: Maximum flow rate - 6.6 L/min (1.75 gal/min) when tested in accordance with ASME A112.18.1/CSA B125.1

Name_______________________ Parcel # ____________________________ BLD#___________________________

Page 1 of 2

Mason CountyDepartment 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 ismade for residential development, or redevelopment¹, with more than 2,000 square feet of impervious surface².

¹Redevelopment means, on an already developed site, the creation or addition of impervious surfaces, structural developmentincluding construction, installation or expansion of a building or other structure, and/or replacement of impervious surface that is notpart 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 thenatural infiltration of stormwater. Open, uncovered retention/detention facilities shall not be considered as impervious surfaces.

To Calculate Impervious Surfaces Please Complete This TableSurface Type Length X Width = Area * All dimensions in feet

Buildings X =X =X =X =

Measurements for buildings are taken at theperimeter of the farthest projections (example:

eaves/gutters)

Driveways X =X =X =

Length of drive begins at the right of way

Parking Areas X =X =X =

Any paved, gravel or packed area per definitionabove table

Patios/Walks X =X =X =

Any paved, gravel or packed area per definitionabove table

Others X = X = X =

Total Impervious Surface Area (sum of all areas)

If the total impervious area of the proposed sitedevelopment is greater than 2000 square feet aSmall Parcel Stormwater Site Plan is Required

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. Ifurther 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 signthe information provided on page 2 of 2.

Name_______________________ Parcel # ____________________________ BLD#___________________________

Page 2 of 2

Mason CountyDepartment 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 StormwaterManagement 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.htmPlease 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 documententitled "Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan". This document will assistyou in preparing the necessary information and plans for Public Works to review and approve. Per Department ofPublic Works this document will constitute an approved plan if all of the relevant details* are to be installed intheir entirety AND no part of the stormwater system adversely affects any septic system (see Environmental Healthinformation 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 Planon 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 installedin 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 thesystem 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 WorksDepartment can provide additional instructions, guidance and examples. (Section 14.48.130) contact Public works at:

Phone: (360)-427-9670 EXT. 450Mail: 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 ofEnvironmental Health to ensure that the stormwater system will not adversely affect the septic system of this, orany other, parcel. You may also wish to consult with the septic design professional involved with the project. MasonCounty Division of Environmental Health can be reached at:

Phone: (360)-427-9670 EXT. 352Mail: 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 metprior 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. Ifurther 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:_______________________

415 N 6th Street, Bldg 8, Shelton WA 98584,

Shelton: (360) 427-9670 ext 400 Belfair: (360) 275-4467 ext 400 Elma: (360) 482-5269 ext 400 FAX (360) 427-7787

This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\ Drinking Water Revised 1/25/2018

WAT ______-_________

Application for Determination of Water Adequacy

Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. 2. Complete only the portion of Part 2 applying to the type of water connection utilized. 3. Submit completed application, with any required attachments for review. 4. An approved building site plan must accompany this application.

Part 1: Applicant/ Parcel Identification

Name on Applicant: Date:

Mailing Address: Phone:

Parcel Number:

Type of Water System

Public/Community Water System (2 or more connections)

Individual water source (one connection),

Well Spring/surface water

Other (explain)_______________

If you have more than one residence connected to this well, check the Public/Community Water System box.

Reason for Application

Building permit

Division of land:

# of Parcels? _______ SPL_______________

Boundary line adjustment

Other (explain)________________

Replacement or Remodel (please indicate name of water system below if applicable – no signature required)

Part 2: Water Connection Information

Complete the section appropriate for the type of water connection being evaluated:

Public Water System

Name of Water System: _______________________________________________

Water Facility Inventory (WFI) Number: ___________________

(write “none” for two-party)

I am the manager of this water system. The water system has been approved for services. There are presently connection(s) in use. This will be the connection.

I am the manager of this system. This connection will be to upgrade or change the use of an existing connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature of this change: _________________________________________

This water system is able and willing to provide water to this (these) connection(s) without exceeding the limits of the water system or any limits set by state and local regulation.

Signature of Water System Manager _______________________________ Date __________________

http://www.co.mason.wa.us/

of 2

Water well report (attached to application). Depth _______________ft.

Well capacity Test (attached to application) ________________gpm ______________gpd.

The well driller often performs well capacity tests at the time the well is constructed. Results from these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test, a well capacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor.

Satisfactory bacteriological test (attach to application).

Development within which WRIA http://gis.co.mason.wa.us/planning 14___ 15___ 16___ 22___

Water use or limitation recorded……………………........... N/A_____ Yes_____ Well Drilled ……………………………………………………… Date _______________

Individual Water Well

Water Resource Inventory Area (WRIA)

Individual Spring/Surface Water

Part 3: Mason County Community Services Evaluation (staff use only)

WDOE permit (attach to application)

Method of disinfection _________________________________________________________

___________________________________________________________________________

I have reason to believe that this water source can provide at least 800 gallons per day; and/or provides water at a rate of 2 gallons per minute based on the following observations.

___________________________________________________________________________

___________________________________________________________________________

Author of Statement _____________________________________ Date _______________

Relationship to Applicant __________________________________

Satisfactory Determination: This determination does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely in the future, or guarantee compliance with all applicable WDOE water resource regulations. Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68.040-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW.

Unsatisfactory Determination: Applicant’s water supply does not appear adequate to meet the needs of its intended use for the following reason(s). __________________________________________________________________

____________________________________________________________________

Reviewer’s Signatures: Environ. Health: _____________________________________ Date __________________

CSD Director: ________________________________ Date___________________

http://gis.co.mason.wa.us/planning

Rev. 12/27/18

Address Request Form/Application

Name: _________________________________________________________ Phone:_______________________________

Mailing Address: _____________________________________________________________________________________

City: ________________________________ State: ______ Zip: ___________ Prefer: Mail or e-Mail notification [Circle One]

E-Mail Address: ______________________________________________________________________________________

Parcel Number: ______________________________________________________________ (12-digit number)

SITE MAP: PLEASE PROVIDE DRIVING DIRECTIONS TO THE PROPERTY (and most importantly a sketch). SHOW WHICH SIDE OF THE ROADWAY YOU WILL BE BUILDING ON IF THE ROAD INTERSECTS YOUR LAND. LIST ANY ADJACENT ADDRESSES YOU ARE AWARE OF AND

NOTATE WHERE YOUR DRIVEWAY IS/WILL BE LOCATED ON THE PARCEL AND NEIGHBORING DRIVEWAYS.

Application fee: $185 due at time of submittal Make checks payable to: Mason County Treasurer Mail application to:

Mason County Permit Center Attn: Addressing Division 615 W. Alder St

Shelton, WA 98584

Addressing questions? Call (360) 427-9670 ext. 365

The Mason County Addressing Ordinance requires you to post your new address

within 30 days of assignment. It must be placed at your driveway entrance

clearly visible from the road in reflective contrasting material.

Address must also be posted to any structure within 30 days of its erection in a contrasting color,

visible from the roadway or driveway.

*******************************************THIS SECTION IS FOR OFFICIAL USE ONLY************************************************

YOUR NEW ADDRESS IS:

RECEIVED � LOGGED IN � TIDEMARK � FIRE DISTRICT __________ BILLED___________ PAID______________ RECEIPT # ____________________________

This checklist MUST be complete. ***A completed ......If project is in a flood hazard area, the...

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