20130106 Permit Pkg 01172013 wo��'�p� City of Yelm Permit No.: 20130106
� �
� Community Development Department Issue Date: 1/17/2013
d (Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
L
"•`«'""°" Fax: (360)458-3144
Applicant:
Name: STATE FARM PROPERTIES Phone:
Address: 104 EDWARDS
YELM WA 98597
Property Information:
Site Address: 104 EDWARDS Owner: STATE FARM PROPERTIES
Assessor Parcel No.: 85800300600 Subdivision: Lot:
Contractor Information:
iName: STATE FARM PROPERTIES Phone:
� Address:
104 EDWARDS
YELM WA 98597
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: RESIDENTIAL REMODEL
Description of Work:
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
BUILDING STATE FARM PROPERTIES $ 25.00
TOTAL FEES: $ 25.00
ApplicanYs Affidavit: � OFFICIAL USE ONLY
I certify that I have re�� e mined the information contained within the application and know the same
to be true and cor��t. I�c rtify that the proposed structure is in conformity with all applicable City of
,, #Sets of Prints:
Yelm regulation includi7g those governing zoning and land subdivision,and in addition,all covenants,
easements an restrict� ns of record. If applying as a contractor, I further certify that I m currently Final Inspection:
registered in the te f V�ashington. u_ _,
...- Date:
Signature Date
, By.
Firm
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Pro�ect Address: ���L
� � P _�j�.��'c/5 Parcel#: �S�bO�i��'>�C�
Subdivision: Lot#: Plan#: Zoning:
❑ New Construction ❑ Re-Model/Re-Roof/Addition ❑ Home Occupation Sign
❑ Plumbing ❑ Mechanical ❑ Mobile/Manufactured Home Placement ❑ Other
Project Description/Scope of Work: ��- ��,�-t"
Project Value: 5�C% , c3��'
Building Area (sq. ft) 1St Floor ���y 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? Nc
/f yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME: s �' ��c a � ���°s ��c
ADDRESS f'�% F?i� � 2��f S EMAIL ✓, „� ,��-��i��.,...i.ar� �n r. �'
CITY 9�c1:i� STATE „c.�4 ZIP �it.S�7 TELEPHONE ?�-E��C�'�nr'_'_�z� �
ARCHITECT/ENGINEER LICENSE#
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTOR C �� S� Ga�, TELEPHONE 3L ,e �`Z y � ifZ�
ADDRESS �s � ��; L/� s� EMAIL
CITY {��,„.� STATE cv ZIP i' FAX
CONTRACTOR'S LICENSE# �7�-T���aS`—�ATE. � CITY LICENSE#
PLUMBING CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE# EXP DATE CITY LICENSE#
i
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.
I hereby the above information is correct and that the construction on,and the occupancy and the use of the
above�escrib�' , rty will be in accordance with the laws,rules and regulations of the State of Washington and the
City of Xelm. :
Z��
Applica 's Sig e Dat
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 Auenue West (360)458-3835
Yelm,WA 98597 (360)458-3I44 FAX
www.ci.yelm.wa.us
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