20120309 Permit Pkg 11012012 QoF''H�p,� City of Yelm Permit ►vo.: 20120309
� � Community Development Department Issue Date: 71/01/2012
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
LM
`".'"'""°" Fax: (360)458-3144
Applicant:
Name: REBECCA LLEWELLYN Phone: 360-458-3646
Address: P.O. BOX 923
YELM WA 98597
Property Information:
site Address: 15941 QUAILMEADOWS Owner: REBECCA LLEWELLYN
Assessor Parcel No.: Subdivision: Lot:
Contractor Information:
Name: REBECCA LLEWELLYN Phone:
Address:
P.O. BOX 923
YELM WA 98597
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: PLUMBING
Description of Work: CHANGE OUT GAS WATER HEATER
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
PLUMBING REBECCA LLEWELLYN $ 27.00
TOTAL FEES: $ 27.00
ApplicanYs Affidavit: OFFICIAL USE ONLY
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 c rtify that the proposed structure is in conformity with all applicable City of #Sets of Prints:
Yelm regulations including tho e governing zoning and land subdivision, and in addition,all covenants,
easem an trictions of r cord. If a plying as a contractor, I further certify that I am currently Final Inspection:
regist red in the a f W i ton.
1 F Date:
Signature Date �
Firm By'
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address:��u 1 �� �'f'Q�1� �� Parcel#:
Subdivision: Lot#: Plan#: Zoning:
� New Construction � Re-Model/Re-Roof/Addition i � Home Occupation Sign
'. Plumbing Mechanical ' Mobile/Manufactured Home Placement � Other
Project Description/Scope of Work:l��_,�f' CX�.� �-r"��P�— �L�C�1f'� ���� f K� '�z'r��k�
Project Value:��( ) "
Building Area(sq. ft) 1S` Floor ( � 2�d Floor�� Garage Deck
Basement Carport Patio
#Bedrooms� #Bathrooms2�1� Heating GAS/ THER or ELECTRIC(Circle One)
Are there any environmentally sensitive areas located on the parcel? n�
/fyes, a completed environmental checklist must accompany permit application.
BUILDI NER NAME: � �C�'� � �
ADDR SS 7 � EMAIL /
CITY \ - STATE >!� ZI TELEPHONE � co
ARCHITECT/ENGINEER LICENSE#
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERALCONTRACTOR 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 TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE# EXP DATE CITY LICENSE#
Copy of mitigation agreement with Yelm Community Schools, if applicable.
1 hereby certify that the above information is correct and that the construction on,and the occupancy and the use of the
above described pr erty will be in accordance with the laws,rules and regulations of the State of Washington and the
City of Yelm.
�-
� - tl r zv��
App i an ignature Date
Owner/ tractor/Own '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.w¢.us
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