Application 04182017CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address:10755 PALISADES ST SE YELM WAParcel #: 67110001800
Subdivision: PALISADES WEST Lot #: 18 Plan #: 3988607 Zoning: RESIDENTIAL
W New Construction Re -Model 1 Re -Roof 1 Addition Home Occupation Sign
C Plumbing Mechanical Mobile 1 Manufactured Home Placement Other
Project DescriptiontScope of Work: NEW CONSTRUCTION/ RESIDENTIAL
Project Value: $350,000
Building Area (sq. ft) 1s` Floor 1905 2"a Floor 3'° Floor Garage -2 car 3 car X
Covered Patio 695 Covered Porch Patio Deck
# Bedrooms 3 # Bathrooms 2 Heating: (GASIOTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel? NO
If yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME: RANDY PAIGEN
ADDRESS POBcx625 EMAIL repai enlive. corn
CITY YELM STATE WA ZIP 98597 TELEPHONE 360-701-7099
ARCHITECT/ENGINEER EXODUS ENDINEERING LICENSE #
ADDRESS 1162 NW STATE AVE EMAIL luke exoduseengineer_corn
CITY CHEHALIS STATE WA ZIP 98532 TELEPHONE 360-918-1369
GENERAL CONTRACTOR owNER , BU LDER TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PLUMBING CONTRACTOR TBD TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR TDB TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
Copy of mitigation agreement with Yelm Community Schools, if applicable.
I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the
above described property will be in accordance with the laws, rules and regulations of the State of Washington and the
Ci elm
Applic nt's Signature Date
Owner ! ContragtorrD—wner's Agent 1 Contractor's Agent (Please circle one.)
All permits are non -transferable and will expire if work authorized by such permit is not begun
within 180 days of issuance, or if work is suspended or abandoned for a period of 180 days
105 Yelm Avenue West (360) 458-3835
Yelm, WA 98597 (360) 458-3144 FAX
www.ci.yelm.w¢.us