20100217 Permit Pkg 11302010City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Applicant:
Name: BLACK HILLS, INC
Address: 1003 85TH AVE SE
OLYMPIA WA 98501
Property Information:
site Address: 203 SOLBERG ST SW owner:
Assessor Parcel No.: 21724410304 Subdivision: NIA
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Permit No.: 20100217
Issue Date: 11/30/2010
(Work must be completed within 180 days)
Phone: 360-239-3776
HELTON
Lot: N/A
Phone: 360-239-3776
Contractor License No.: BLACKH1066JL Expires: 3/31/2009
Project Information:
Project: MECHANICAL
Description of Work: REPLACE EXISTING FURNACE
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
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 and restrictions of record. If applying as a contractor, I further certify that I am currently
registered in the State of Washington.-A
Signature C~ SD+--~, Date i i 13a 1~ v
Firm
Fees
$ 29.50
S 29.50
OFFICIAL USE ONLY
Sets of Prints:
final Inspection:
Date:
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CITY OF YELM
RESI~EJ~FAf.--13tfF6 ING PERMIT APPLICATION FORM
Project Address: Parcel #:
Subdivision: Lot #: Plan #: Zoning:
L New Construction Re-Model / Re-Roof /Addition -Home Occupation Sign
Plumbing /Mechanical Mobile /Manufactured Home Placement ~_~ Other
Project Description/Scope of Work: ~9..a~~~ P Q Q.. L'"~{ 9~ ~.1P~r'~ ,
Project Value:
Building Area (sq. ft) 1 g' Floor 2"d Floor Garage Deck
Basement Carport Patio
# 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 n~ER NAME: a
ADDRESS,Zj ~~ EMAIL
CITY y~~1 STATE '~ ZIP ~~~~TELEPHON
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 Z1P FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR" TELEPHONE?7loD •`"I(~~ ,SG1D
ADDRESS ( ~' EMAIL
CITY STATE ZIP FAX
CONT CTOR'S LICENSE #' tFXP 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
City of Yelm.
i~
Da e
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 Yedm Avenue West (360) 458-3835
Yelm, WA 98597 (360) 458-3144 FAX
www.ci.yelm.wa.us