20090230 Permit Pkg 110609City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360)458-3144
Applicant:
Name: EDWARD & KATH NEIBURGER
Address: P.O. BOX 820
YELM WA 98597
Property Information:
site Address: g$04 RAMSAY
Assessor Parcel No.: 69240005900 Subdivision:
Contractor Information:
Name: TOP NOTCH CHIMNEY & STOVE
Address: MARK A COX
17324 FLUME RD
YELM WA 98597
Contractor License No.: TOPNOCSO44KL Expires
Permit No.: 20090230
Issue Date: 11/06/2009
(Work must be started within 180 days)
Phone:
Owner: ED & KATHY NEIBURGER
Lot:
Phone:
1 /13/2011
Project Information:
Project: MECHANICAL
Description of Work: INSTALL PACIFIC ENERGY WOOD STOVE, MODEL D WH113258
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Units
MECHANICAL PERMIT 1
WHOLE HOUSE FAN/MISCELLANEOUS 1
TOTAL FEES:
PAYMENTS MADE:
BALANCE DUE:
$ 20.00
$ 9.50
$ 29.50
$ 0.00
$ 29.50
Applicant's Affidavit:
I certify that I have read and examined the information contained within the application and know the same
to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of
Yelm regulations including those governing zoning and land subdivision, and in addition, all covenants,
easements and restrictions of record. If applying as a contractor, I further certify that I am currently
registered inythDe State of Wash/in~gton. 9
Signature `,~,,~~f~l~/ ` -!/I Date 1~~~
Firm
OFFICIAL USE ONLY
# Sets of Prints:
Finallnspection:
Date:
By:
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CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: ! ~d~ /~~~~ ~, f - Parcel #:
Subdivision: ~P Lot #: Plan #: Zoning:
New Construction ~ ~ ' Re-Model / Re-Roof /Addition 'Home Occupation Sign
Plumbing Mechanical Mobile /Manufactured Home Placement 'Other
Project Description/Scope of Wor~C: M/ Q~_~Z„S, ~01/ P
Project Value: ~_~:~•Qeh t~
Building Area (sq. ft) 15t Floor_~~ 2"d Floor Garage ~ Deck~/~
Basement /UIO Carport N CJ Patio' ~Q
# Bedrooms # Bathrooms Heating: GAS/OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel? _~~
If yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME: w
ADDRESS EMAIL
CITY STAT P TELEPHONE
ARCHITECT/ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE_CITY LICENSE #
PLUMBING CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE_CITY LICENSE #
MECHANICAL CONTRACTOR ~/n r4! `) TELEPHONE yS ~$at V-L
ADDRESS EMAIL
CITY ATE ZIP FAX
CON RACTOR'S L CENSE # TD a Isla s'SAEXP DATE_CITY LICENSE #
Copy of mitigation agreement with Yelm Comm'7i hity 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
City of Yelm.
Applicant's Signature Date
Owner /Contractor /Owner's Agent /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.wa.us
r•.
A '. ~
Chimn~' ~ Stove
~'~ Notch Cyim~J'
~phat's Up Your __ 1
Serving aU Washington
with Sweeps, InstaLiaatt°~
and RePa=rs
q58-8262
Cell: (~) ~ 8281
Mark Cox p~,iner/Operator
PNOCSp44KL Fax: (~)
Lic. # TO ~~ured Wp 98597
Bonded & 4 Flume Rd. S•E•~Yelm,
1732
~~;'~~:
TOP NOTCH CHIMNEY & STOVE
~~~, ~`~ TOPNOCS044KL
~~; ` 601-592-106 ~-
p~~E • `~ COX, MARK A
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(360)458-8262
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~~.' -.:- 17324 FLUME RD SE
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YELM
~. => . _ ~ ~` 98597
~:;r 01 /13/2011
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Austad Name:
Su~serid Date