20100019 Permit Pkg 012910City of Yelm
Community Development Department
Building Division
Phone: (380)458-8407
Fax: (380) 458-3144
Applicant:
Name: BLACK HILLS, INC
Address: 1003 85TH AVE SE
OLYMPIA WA 98501
Property Information:
Site Address: 15dA1 107TH l P SF
Permit No.: 20100019
Issue Date: 1/29/2010
(Work must be started within 180 days)
Phone: 360-239-3776
Owner: SARAH CONNELISON
Assessor Parcel No.: 81580000200 Subdivision:
Contractor Information
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Lot:
Phone: 360-239-3776
Contractor License No.: BLACKH1066JL Expires: 07/31/12
Project Information:
Project: MECHANICAL
Description of Work:
Sq. Ft. per floor: First
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Heat Type (Electric, Gas, Other):
Contractor
BLACK HILLS, INC
TOTAL FEES:
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 restrictions of record. If applying as a contractor, I further certify that I am currently
registered o Washin 1 1 ~
Si nature ~ Vl~ Date
Firm
~ Fees
$ 29.50
S 29.50
Sets of Prints:
nallnspection:
Date:
Jan 27 ?010 5:45 }31ack Hills, Inc. 705H584 page
'~ ~ ~ Ud
GITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 154°1 ! !m b^ L Parcel #: $1 ~ OOi~~bO
Subdivision: Lot #: Plan #:
O New Construcdo ^ Re-Model / Re-Roof /Addition D Home Occupation Sign
D Plumbing ~ Mechanbal ^ Mobile /Manufactured Home Placement o Other
Project Description/Scope of Work: 5,~~c~ ti,,,- GIrv -`J'~a ~vY'r'10.D,~
Project Value:
Building Area (aq. ft) 1 ~ Floor 2rd Fbor Garage Deck
Basement Carport Patio
# Bedr+ooms_ # Bathrooms- Heating: GAS/OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel?
!f yes, a completed environmental chedciist must accompany permit application.
I heroby CYttlfy thlrt ttN atwvo Infonmaflon b cornact and that the comtructlon on, and 1M occupancy and tM use of tho
ttiow dwcrltasd proporty will 6o In acconianw wMh tho taws, rules and r+pulatlona of the Stilts of YMashlnpton and tha
City of Y~Im.
~,.~_p lr,lr_i.t ~ ,
' pplicanYs Signature ~ e
Owner !Contractor /Owner's Agant !Contractor's Agent (Please circle one.)
All petTrtlts are rton-transferable and will expire if work authorized by such penrnit its not begun
within 180 days of fissuance~ or if work fis suspended or abandoned for a period of 180 days
tOb Yetn Avenue Weet (d60) 4b8-5885
Ye1m, W.t 8859 (d60) Id8-8141 FAX
tcnoto.el.rtlm.waua
Copy of mfigation agreement with Yelm Community Schools, if applicable.
City of Y~lm
t:?F~Q:' ~~58-840
F~Er,D: 0t~~~~;4.~ =J0~1~010 1:50 PM
OP'ER: G~J TERM: 001
P'EFq: 1I.07f~
IRAN: =~3.OOQ0 HUILPINr PERMITS
?OlOi~?l`~ ~'~.50C~'
SLACK HILLS, INC
1549I ? 0?TH I_P SE
~rCH ~~.S~~CR
TENDERED: ~'~.50 C~Ch`.
RE'P'LIED: ~'~.50-
GRANGE: 0, 0•;