Fillable Bld Permit Packet

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Bld Permit Packet

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  • 211 check-boxes
  • 299 other fields

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APPLICANT INFORMATION (please print clearly)
Name of
Applicant: ______________________________________ Parcel Number: _____________________
Site Address: ______________________________________________________________________________
This checklist must be completed and signed by the owner or owners authorized agents at
time of submittal.
Incomplete applications will NOT be accepted. For a complete application, all items on this checklist
shall be submitted, unless waived by Staff.
PERMIT APPLICATION
N/A
Provided
Staff
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.
Other:
Zoning (indicate):
Rural Residential: 2.5 5 10
20
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 at all four corners of structure.
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.
PLANS
N/A
Provided
Staff
Provide three (2) copies of plans (1 full size min. 18”x 24” and 1 small size) and
BLD
_______-_________
RCVD B
Y:
DATE STAMP
two (1) 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
callouts must be on plans.
Engineered plans must provide calculations/analysis. Analysis must include the
following information:
• 2018 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 floodplain 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)
ELEVATIONS AND WALL DETAILS
Typical and rated walls (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
N/A
Provided
Staff
Completed Washington State Energy Code form
Plans must indicate fuel source for furnaces, water heaters and other appliances.
Manufactures Specifications for each unit or component for HVAC & plumbing
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 number 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.
_________
_______________________________ ______________________________________ ____________
Signature of owner or authorized agent Print Name Date
click to sign
signature
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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 _______________________________________________________
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signature
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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:________
1
st
PHONE:____________________________________
2
nd
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 – 1
ST
FLOOR_____ 2
ND
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:________________
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signature
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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.
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.
2. North arrow
3. Property line location and dimensions.
4. Label abutting streets
5. Shoreline/Surface water: Indicate creeks, streams, lakes, ponds, wetlands and
other bodies of water within 300 ft of the proposed project.
6. Wetlands and Seasonal Drainage: Show setback distances from wetlands or
seasonal drainage.
7. Easements: Indicate location and size of road, utility, and private easements.
8. Show All Existing Development: Identify existing and proposed structures.
Include porches, decks, roof overhangs, cantilevers, and structures that will be
demolished.
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.
10. Sewage Disposal System: Identify septic tank location and drainfield.
11. Existing and proposed Buffers: Include open space, fences, sidewalks and
parking areas.
12. Retaining walls: Proposed and existing.
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.
14. Wells: Show existing and proposed, need to include all wells located within
100 ft of property.
15. Waterfront projects: Show all structures on adjacent property.
16. Driveway/ Site Access
17. Stormwater Run-off Path: Identify stormwater run-off path and direction of
flow.
18. Land modification/Grading permits: Site applications for land modification
permits must show topography before and after the proposed work.
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’
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
INSTRUCTIONS FOR COMPLIANCE TO THE
2018 IECC, as amended by WSEC- WAC 51-11 (IECC)
Effective February 1, 2021
Ventilation code provisions are in the 2018 International Residential Code (IRC),
2018 International Mechanical Code (IMC), & 2018 International Building Code
A complete energy code application form will include information that clearly identifies compliance methods
for heating and cooling, thermal envelope, energy credits, manufactures specifications and whole-house
ventilation. 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 .
INSTRUCTIONS: 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 details must be shown on your construction drawing.
1. 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.
2. 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 on the plan detail pages.
Construction drawings must include all construction details and specification for all WSEC
requirement and options chosen. All new one and two-family dwelling unit and townhouses
are required to achieve the following minimum number of credit options:
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Small Dwelling Unit: 3 credits. Dwelling units less than 1,500 sf in conditioned floor area with
less than 300 sf of fenestration area. Additions to existing building that are greater than 500 sf of
heated floor area but less than 1,500 sf.
Medium Dwelling Unit: 6 credits. All dwelling units that are not included in #1 or #3
Large Dwelling Unit: 7 credits. Dwelling units exceeding 5,000 sf of conditioned floor area.
Additions less than 500 square feet: 1.5 credits. All other additions shall meet 1-3 above.
3. Must meet the prescriptive option for all fenestration products. Products shall comply with the
required U-factor listed in Table R402.1.1. Windows, doors, and glazed doors shall have a tested
U-factor or .30 or less. Details must be shown on plan pages.
4. 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.
5. Identify on the construction drawings the location and fuel type of the heating system, water heater,
location, and CFM’s 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.
6. Must attached/provide copies of specifications sheets for an HVAC and WSEC components
providing details for compliance.
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
COMING SOON>>>New 2018 Code Compliance Calculator: This new compliance tool is designed
for both R402.1.1 (prescriptive) and R402.1.4 (UA Component) paths. It includes the glazing
calculator and simple heating system sizing all in one worksheet. This tool can also calculate
Efficient Building Envelope Options 1.3 – 1.6 using the % UA reduction in R402.1.1 path, in lieu of
using the specific measure receipts highlighted below. This option in this new tool provides more
flexibility to optimize energy credits, based on custom envelope measures. WSU is completing
testing of this tool, which should be available in 2021.
For more information and details:
http://www.energy.wsu.edu/documents/Prescriptive%20Checklist%202018_rev%2012-4-20.pdf
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
These requirements apply to all IRC building types, including detached one- and two-family dwellings and multiple
single-family dwellings (townhouses).
Contact Information
Project Information
Owners Name:
Site Address:
Mailing Address:
Parcel Number:
Square Feet (total):
Ventilations Compliance:
Whole House Ventilation system
using exhaust fans & window or wall
fresh air vents (M1507.3.4)
Whole House Ventilation
Integrated with a Forced Air
System (M1507.3.5)
Other, describe:
Instructions: This single-family project will use the requirements of the Prescriptive Path below and
incorporate the minimum values listed. Based on the size of the structure, the appropriate number of
additional credits are checked as chosen by the permit applicant.
Provide all information from the following tables as building permit drawings: Table R402.1 - Insulation and
Fenestration Requirements by Component, Table R406.2 - Fuel Normalization Credits and 406.3 - Energy Credits.
All Climate Zones (Table R402.1.1)
R-Value
a
U-Factor
a
Fenestration U-Factor
b
n/a
0.30
Skylight U-Factor
b
n/a
0.50
Glazed Fenestration SHGC
b
,
e
n/a
n/a
Ceiling
e
49
j
0.026
Wood Frame Wall
g,h
21 int
0.056
Floor
30
0.029
Below Grade Wall
c,h
10/15/21 int + TB
0.042
Slab
d,f
R-Value & Depth
10, 2 ft
n/a
a
R-values are minimums. U-factors and SHGC are maximums. When insulation is installed in a cavity that is less
than the label or design thickness of the insulation, the compressed R-value of the insulation from Appendix
Table A101.4 shall not be less than the R-value specified in the table.
b
The fenestration U-factor column excludes skylights.
c
"10/15/21 +5TB" means R-10 continuous insulation on the exterior of the wall, or R-15 continuous insulation on
the interior of the wall, or R-21 cavity insulation plus a thermal break between the slab and the basement wall at
the interior of the basement wall. "10/15/21 +5TB" shall be permitted to be met with R-13 cavity insulation on
the interior of the basement wall plus R-5 continuous insulation on the interior or exterior of the wall. "5TB"
means R-5 thermal break between floor slab and basement wall.
d
R-10 continuous insulation is required under heated slab on grade floors. See Section R402.2.9.1.
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
e
For single rafter- or joist-vaulted ceilings, the insulation may be reduced to R-38 if the full insulation depth
extends over the top plate of the exterior wall.
f
R-7.5 continuous insulation installed over an existing slab is deemed to be equivalent to the required perimeter
slab insulation when applied to existing slabs complying with Section R503.1.1. If foam plastic is used, it shall
meet the requirements for thermal barriers protecting foam plastics.
g
For log structures developed in compliance with Standard ICC 400, log walls shall meet the requirements for
climate zone 5 of ICC 400.
h
Int. (intermediate framing) denotes framing and insulation as described in Section A103.2.2 including standard
framing 16 inches on center, 78% of the wall cavity insulated and headers insulated with a minimum of R-10
insulation.
Each dwelling unit in a residential building shall comply with sufficient options from Table R406.2 (fuel
normalization credits) and Table 406.3 (energy credits) to achieve the following minimum number of
credits. To claim this credit, the building permit drawings shall specify the option selected and the
maximum tested building air leakage and show the qualifying ventilation system and its control sequence
of operation.
1. Small Dwelling Unit: 3 credits
Dwelling units less than 1,500 sf in conditioned floor area with less than 300 sf of fenestration area.
Additions to existing building that are greater than 500 sf of heated floor area but less than 1,500 sf.
2. Medium Dwelling Unit: 6 credits
All dwelling units that are not included in #1 or #3
3. Large Dwelling Unit: 7 credits
Dwelling units exceeding 5,000 sf of conditioned floor area
4. Additions less than 500 square feet: 1.5 credits
All other additions shall meet 1-3 above
Before selecting your credits on this Summary table, review the details in Table 406.3 (Single Family), on page 4.
Summary of
Table R406.2
Heating
Options
Fuel Normalization Descriptions
Credits - select ONE
heating option
User Notes
1
Combustion heating minimum NAECA
b
0.0
2
Heat pump
c
1.0
3
Electric resistance heat only - furnace or zonal
-1.0
4
DHP with zonal electric resistance per option 3.4
0.5
5
All other heating systems
-1.0
Energy
Options
Energy Credit Option Descriptions
Credits - select ONE
energy option from each
category
d
1.1
Efficient Building Envelope
0.5
1.2
Efficient Building Envelope
1.0
1.3
Efficient Building Envelope
0.5
1.4
Efficient Building Envelope
1.0
1.5
Efficient Building Envelope
2.0
1.6
Efficient Building Envelope
3.0
1.7
Efficient Building Envelope
0.5
2.1
Air Leakage Control and Efficient Ventilation
0.5
2.2
Air Leakage Control and Efficient Ventilation
1.0
2.3
Air Leakage Control and Efficient Ventilation
1.5
2.4
Air Leakage Control and Efficient Ventilation
2.0
3.1
a
High Efficiency HVAC
1.0
3.2
High Efficiency HVAC
1.0
3.3
a
High Efficiency HVAC
1.5
3.4
High Efficiency HVAC
1.5
3.5
High Efficiency HVAC
1.5
3.6
a
High Efficiency HVAC
2.0
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
4.1
High Efficiency HVAC Distribution System
0.5
4.2
High Efficiency HVAC Distribution System
1.0
a.
An alternative heating source sized at a maximum of 0.5 W/sf (equivalent) of heated floor area or 500 W,
whichever is bigger, may be installed in the dwelling unit.
b.
Equipment listed in Table C403.3.2(4) or C403.3.2(5)
c.
Equipment listed in Table C403.3.2(1) or C403.3.2(2)
d.
You cannot select more than one option from any category EXCEPT in category 5. Option 5.1 may be combined
with options 5.2 through 5.6. See Table 406.3.
e.
1.0 credit for each 1,200 kWh of electrical generation provided annually, up to 3 credits max.
See the complete Table R406.2 for all requirements and option descriptions.
5.1
d
Efficient Water Heating
0.5
5.2
Efficient Water Heating
0.5
5.3
Efficient Water Heating
1.0
5.4
Efficient Water Heating
1.5
5.5
Efficient Water Heating
2.0
5.6
Efficient Water Heating
2.5
6.1
e
Renewable Electric Energy (3 credits max)
1.0
7.1
Appliance Package
0.5
Total
Credits
Please print only pages 1 through 3 of this worksheet for submission to your building official.
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Table 406.3 – Energy Credits (Single Family)
Option
Description
Credits: SF
1. EFFICIENT BUILDING ENVELOPE OPTIONS
Only one option from Items 1.1 through 1.7 may be selected in this category.
Compliance with the conductive UA targets is demonstrated using Section R402.1.4, Total UA alternative, where [1-
(Proposed UA/Target UA)] > the required %UA reduction.
1.1
Prescriptive compliance is based on Table R402.1.1 with the following modifications:
Vertical fenestration U = 0.24
0.5
1.2
Prescriptive compliance is based on Table R402.1.1 with the following modifications:
Vertical fenestration U = 0.20
1.0
1.3
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 conductive UA by 5%
0.5
1.4
Prescriptive compliance is based on Table R402.1.1 with the following modifications:
Vertical fenestration U = 0.25
Wall R-21 plus R-4 ci
Floor R-38
Basement wall R-21 int plus R-5 ci
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 conductive UA by 15%
1.0
1.5
Prescriptive compliance is based on Table R402.1.1 with the following modifications:
Vertical fenestration U = 0.22
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
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 conductive UA by 30%
2.0
1.6
Prescriptive compliance is based on Table R402.1.1 with the following modifications:
Vertical fenestration U = 0.18
Ceiling and single-rafter or joist-vaulted R-60 advanced
Wood frame wall R-21 int plus R-16 ci
Floor R-48
Basement wall R-21 int plus R-16 ci
Slab on grade R-20 perimeter and under entire slab Below grade slab R-20 perimeter and
under entire slab or
Compliance based on Section R402.1.4: Reduce the Total conductive UA by 40%.
3.0
1.7
Advanced framing and raised heel trusses or rafters
Vertical Glazing U-0.28
R-49 Advanced (U-0.020) as listed in Section A102.2.1, Ceilings below a vented attic and
R-49 vaulted ceilings with full height of uncompressed insulation extending over the wall
top plate at the eaves.
0.5
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Table 406.3 – Energy Credits (Single Family)
Option
Description
Credits: SF
2. AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION OPTIONS
Only one option from Items 2.1 through 2.4 may be selected in this category.
2.1
Compliance based on R402.4.1.2: Reduce the tested air leakage to 3.0 air changes per hour
maximum at 50 Pascals or
For R-2 Occupancies, optional compliance based on Section R402.4.1.2: Reduce the tested
air leakage to 0.3 cfm/sf maximum at 50 Pascals and
All whole house ventilation requirements as determined by Section M1507.3 of the
International Residential Code or Section 403.8 of the International Mechanical Code shall
be met with a high efficiency fan(s) (maximum 0.35 watts/cfm), not interlocked with the
furnace fan (if present). 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 the maximum tested building air leakage, and shall show the qualifying
ventilation system and its control sequence of operation.
0.5
2.2
Compliance based on Section R402.4.1.2: Reduce the tested air leakage to 2.0 air changes
per hour maximum at 50 Pascals or
For R-2 Occupancies, optional compliance based on Section R402.4.1.2: Reduce the tested
air leakage to 0.25 cfm/sf maximum at 50 Pascals and
All whole house ventilation requirements as determined by Section M1507.3 of the
International Residential Code or Section 403.8 of the International Mechanical Code shall
be met with a heat recovery ventilation system with minimum sensible heat recovery
efficiency of 0.65.
1
1.0
2.3
Compliance based on Section R402.4.1.2:
Reduce the tested air leakage to 1.5 air changes per hour maximum at 50 Pascals or
For R-2 Occupancies, optional compliance based on Section R402.4.1.2: Reduce the tested
air leakage to 0.25 cfm/sf maximum at 50 Pascals and
All whole house ventilation requirements as determined by Section M1507.3 of the
International Residential Code or Section 403.8 of the International Mechanical Code shall
be met with a heat recovery ventilation system with minimum sensible heat recovery
efficiency of 0.75.
1
1.5
2.4
Compliance based on Section R402.4.1.2:
Reduce the tested air leakage to 0.6 air changes per hour maximum at 50 Pascals or
For R-2 Occupancies, optional compliance based on Section R402.4.1.2: Reduce the tested
air leakage to 0.15 cfm/sf maximum at 50 Pascals and
All whole house ventilation requirements as determined by Section M1507.3 of the
International Residential Code or Section 403.8 of the International Mechanical Code shall
be met with a heat recovery ventilation system with minimum sensible heat recovery
efficiency of 0.80. Duct installation shall comply with Section R403.3.7.
1
2.0
1
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 heat recovery ventilation system.
2018 Washington State Energy Code – Residential
Prescriptive Energy Code Compliance for All Climate Zones in Washington
Single Family – New & Additions (effective February 1, 2021)
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Table 406.3 – Energy Credits (Single Family)
Option
Description
Credits: SF
3. HIGH EFFICIENCY HVAC EQUIPMENT OPTIONS
Only one option from Items 3.1 through 3.6 may be selected in this category.
3.1
2
Energy Star rated (U.S. North) Gas or propane furnace with minimum AFUE of 95% or
Energy Star rated (U.S. North) Gas or propane boiler with minimum AFUE of 90%.
2
1.0
3.2
2
Air-source centrally ducted heat pump with minimum HSPF of 9.5.
3
1.0
3.3
2
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.
3
1.5
3.4
Ductless mini-split heat pump system, zonal control: In homes where the primary space
heating system is zonal electric heating, a ductless mini-split heat pump system with a
minimum HSPF of 10.0 shall be installed and provide heating to the largest zone of the
housing unit.
4
1.5
3.5
2
Air-source, centrally ducted heat pump with minimum HSPF of 11.0.
4
1.5
3.6
2
Ductless split system heat pumps with no electric resistance heating in the primary living
areas. A ductless heat pump system with a minimum HSPF of 10 shall be sized and
installed to provide heat to entire dwelling unit at the design outdoor air temperature.
To qualify to claim this credit, the building permit drawings shall specify the option being
selected, the heated floor area calculation, the heating equipment type(s), the minimum
equipment efficiency, and total installed heat capacity (by equipment type).
2.0
2
An alternative heating source sized at a maximum of 0.5 W/sf
(equivalent) of heated floor area or 500 W, whichever is
bigger, may be installed in the dwelling unit.
3
To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify
the heating equipment type and the minimum equipment efficiency.
4
To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify
the heating equipment type and the minimum equipment efficiency.
4. HIGH EFFICIENCY HVAC DISTRIBUTION SYSTEM OPTIONS
4.1
All supply and return ducts located in an unconditioned attic shall be deeply buried in
ceiling insulation in accordance with Section R403.3.7.
For mechanical equipment located outside the conditioned space, a maximum of 10 linear
feet of return duct and 5 linear feet of supply duct connections to the equipment may be
outside the deeply buried insulation. 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.
Duct leakage shall be limited to 3 cfm per 100 square feet of conditioned floor area.
Air handler(s) shall be located within the conditioned space.
0.5
4.2
HVAC equipment and associated duct system(s) installation shall comply with the
requirements of Section R403.3.7.
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.
To qualify to claim this credit, the building permit drawings shall specify the 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
2018 Washington State Energy Code – Residential
Prescriptive Energy Code Compliance for All Climate Zones in Washington
Single Family – New & Additions (effective February 1, 2021)
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Table 406.3 – Energy Credits (Single Family)
Option
Description
Credits: SF
5. EFFICIENT WATER HEATING OPTIONS
Only one option from Items 5.2 through 5.6 may be selected in this category. Item 5.1 may be combined with any option.
5.1
A drain water heat recovery unit(s) shall be installed, which captures waste water heat from
all and only the showers, and has a minimum efficiency of 40% if installed for equal flow or a
minimum efficiency of 54% if installed for unequal flow. Such units shall be rated in
accordance with CSA B55.1 or IAPMO IGC 346-2017 and be so labeled.
To qualify to claim this credit, the building permit drawings shall include a plumbing diagram
that specifies the drain water heat recovery units and the plumbing layout needed to install it.
Labels or other documentation shall be provided that demonstrates that the unit complies
with the standard.
0.5
5.2
Water heating system shall include one of the following:
Energy Star rated gas or propane water heater with a minimum UEF of 0.80.
5
0.5
5.3
Water heating system shall include one of the following:
Energy Star rated gas or propane water heater with a minimum UEF 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
Water heater heated by ground source heat pump meeting requirements of Option 3.3.
To qualify to claim this credit, the building permit drawings shall specify the option being
selected and shall specify the water heater equipment type and the minimum equipment
efficiency and, for solar water heating systems, the calculation of minimum energy savings.
1.0
5.4
Water heating system shall include one of the following:
Electric heat pump water heater meeting the standards for Tier I of NEEA's advanced water
heating specification or
For R-2 Occupancy, electric heat pump water heater(s), meeting the standards for Tier I of
NEEA's advanced water heating specification, shall supply domestic hot water to all units. If
one water heater is serving more than one dwelling unit, all hot water supply and
recirculation piping shall be insulated with R-8 minimum pipe insulation.
5
1.5
5.5
Water heating system shall include one of the following: Electric heat pump water heater
meeting the standards for Tier III of NEEA's advanced water heating specification or
For R-2 Occupancy, electric heat pump water heater(s), meeting the standards for Tier III of
NEEA's advanced water heating specification, shall supply domestic hot water to all units. If
one water heater is serving more than one dwelling unit, all hot water supply and
recirculation piping shall be insulated with R-8 minimum pipe insulation.
5
2.0
5.6
Water heating system shall include one of the following:
Electric heat pump water heater with a minimum UEF of 2.9 and utilizing a split system
configuration with the air-to-refrigerant heat exchanger located outdoors. Equipment shall
meet Section 4, requirements for all units, of the NEEA standard Advanced Water Heating
Specification with the UEF noted above or
For R-2 Occupancy, electric heat pump water heater(s), meeting the standards for Tier III of
NEEA's advanced water heating specification and utilizing a split system configuration with
the air-to-refrigerant heat exchanger located outdoors, shall supply domestic hot water to all
units. If one water heater is serving more than one dwelling unit, all hot water supply and
recirculation piping shall be insulated with R-8 minimum pipe insulation.
5
2.5
5
To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall
specify the water heater equipment type and the minimum equipment efficiency.
2018 Washington State Energy Code – Residential
Prescriptive Energy Code Compliance for All Climate Zones in Washington
Single Family – New & Additions (effective February 1, 2021)
Prescriptive Path – Single Family
2018 Washington State Energy Code-R
Table 406.3 – Energy Credits (Single Family)
Option
Description
Credits: SF
6. RENEWABLE ELECTRIC ENERGY OPTION
6.1
For each 1200 kWh of electrical generation per housing unit provided annually by on-site
wind or solar equipment a 1.0 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 or approved alternate by
the code official.
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.
1.0
7. APPLIANCE PACKAGE OPTION
7.1
All of the following appliances shall be new and installed in the dwelling unit and shall meet
the following standards:
Dishwasher – Energy Star rated
Refrigerator (if provided) – Energy Star rated
Washing machine – Energy Star rated
Dryer – Energy Star rated, ventless dryer with minimum CEF rating of 5.2
To qualify to claim this credit, the building permit drawings shall specify the option being
selected and shall show the appliance type and provide documentation of Energy Star
compliance. At the time of inspection, all appliances shall be installed and connected to
utilities. Dryer ducts and exterior dryer vent caps are not permitted to be installed in the
dwelling unit.
0.5
Name_______________________ Parcel # ____________________________ BLD#___________________________
Page 1 of 2
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 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 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=
X=
X=
Measurements for buildings are taken at the
perimeter 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 definition
above table
Patios/Walks
X=
X=
X=
Any paved, gravel or packed area per definition
above table
Others
X=
X
=
X
=
Total Impervious Surface Area (sum of all areas)
If the total impervious area of the proposed site
development is greater than 2000 square feet a
Small 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. 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.
Name_______________________ Parcel # ____________________________ BLD#___________________________
Page 2 of 2
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/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 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:_______________________
415 N 6
th
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 __________________
Page 2 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___________________
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 # ____________________________
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