20130246 Permit Pkg 06212013 o� City of Yelm Permit No.: 20130246
� Community Development Department Issue Date: 6/21/2013
�
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
w" ' FBX: (360)458-3144
Applicant:
Name: DALE WOOD Phone: 360-458-5540
Address: 15708 123RD AVE SE
YELM WA 98597
Property Information:
site Address: 16343 BIRKLAND ST SE Owner: DALE WOOD
Assessor Parcel No.: Subdivision: Lot:
Contractor Information:
Name: DALE WOOD Phone:
Address:
15708 123RD AVE SE
YELM WA 98597
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: ROOF
Description of Work: REROOF
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
ROOF DALE WOOD $ 25.00
TOTAL FEES: $ 25.00
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.1 also certify that the proposed structure is in conformity with all applicable City of #Sets of Prints:
Yelm regulations including those governi zoning and land subdivision,and in addition,all covenants,
easements and restrictions of record. If lying as contractor, I further certify that I am currently Final Inspection:
registered in the ate of Washington. __
Signature Date `� ��� � ` Date:
Firm By�
Cit� of Y�lm
(36 ) 458-84U2
REC#: 00131167 6/21/2013 2:37 PM
OPER: CO TERM; 001
REF#: 6355
�CRAN: 33.OU00 BUILDING PERh1IT5
2U130C46 25.00CR
WOOD, DALE
16343 BIRKLAND ST SE
ROOF 25.00CR
TENpERED: 25,00 CHECK
APPLIED: 25.00-
CHANGE: v� 0.00
CITY OF YELM ��3 ����
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: /(,� 3 y� �/L,3�! � Parcel#:
(s'��e l�C 1 r� ,� �
Subdivision: Lot#: Plan#: Zoning:
❑ New Construction ❑ Re-Model Re-Roof/Addition ❑ Home Occupation Sign
❑ Plumbing ❑ Mechanical ❑ o i e/Manufactured Home Placement ❑ Other
Project Description/Scope of Work: � �_ I(��v k�
� ��
Project Value: �/.S�C�
Building Area (sq. ft) 15' Floor 2"d Floor 3�d Floor Garage-2 car 3 car
Covered Patio Covered Porch Patio Deck
# Bedrooms_ # Bathrooms_ Heating: GAS/OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel?
/f yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME: ,J�
ADDRESS� S �c,l�3 j.2 ;�--�� EMAIL
CITY = /,v� STATE , Jr1- ZIP C' TELEPHONE ,- � S" -,.S�S�uc--
ARCHITECT/ENGINEER LICENSE#
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAICONTRACTOR 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.
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.
r)� �, ,c.J���� �����/ 3
Applicant's ignature Date
Owner I Contractor I 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)458-3144 FAX
www.ci.yelm.wa.us