20130282 Permit Pkg 07302013 OOF TH�p� City of Yelm Permit No.: 20130282
0. �, Community Development Department Issue Date: 7/30/2013
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
LM
MiA6NIMGtOF Fax: (360)458-3144
Applicant:
Name: BLACK HILLS, INC Phone: 360-239-3776
Address: 1003 85TH AVE SE
OLYMPIA WA 98501
Property Infortnation:
Site Address: 14921 MT VIEW CT Owner: TYPE CURRENT OWNER
NAME
Assessor Parcel No.: 42990000900 Subdivision: COUNTRY VISTA Lot: 9
Contractor Information:
Name: BLACK HILLS, INC Phone: 360-239-3776
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL Expires: 3/31/2009
Project Information:
Project: MECHANICAL
Description of Work: INTALL HEAT PUMP AND REPLACE FURNANCE DUCT TEST RESULTS AND CO ALARM
REQUIRED
Sq. Ft. per floor: First Heat Type(Electric,Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
MECHANICAL BLACK HILLS, INC $ 29.50
TOTAL FEES: $ 29.50
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 certify that the proposed structure is in conformity with all applicable City of #Sets of Prints:
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 Final Inspection:
registered in the State of Washington.
Signature � ' /Ly.� Date � �3�'� �3 Date:
7( By:
Firm ��oiL �� tt•���S : '1(�
Cit� of Y�1�
cs6 ) a5a-saoz
REC#: 00134396 7/30/2013 12:39 PM
OPER: CD TERM: 001
REF#: 14305
TRAN: 33.0000 BUILDING PERMITS
20130282 29.5UCR
BLACK HILLS, INC
14921 MT VIEW CT
MECH 29.50Cf�
TENDERED, 29.50 CHECK
APPLIED: 29.50-
CHANGE; ~ 0.00
FROM black hills <TUE)JUL 30 2013 7:23/ST. T:22/No.7600000864 P l
�/ � ��
CITY OF YELM
RESIDENTU0.L BUILDINO PERMIT APPUCATION FORM
Project Address: ��q a'� '(�� v tR�� � Parcel#: �-a QR vUC3Uq U U
Subdivision: Lot#: Plan#: Zoning:
o New Construction ❑ Re-Model/Re-Roof I Addition ❑ Home Occupation Sign
�� Plumbing `.4�Mechanical � Mobile/Manufactured Home Placement ❑ Other
Project Description/Scope of Work:�,�'�� �U�✓nY} � c�Q.l? Ce.l'�. � ,
Pt��e: � �< <. .� -t _ r� - '�,Cr � �'S �i � r f t � �� t.�-� i .'l r j�t L�U t�1°�-��
Building Area(sq.ft} 1�'Floor 2nd Floor Garage Deck
Basement Carport Patio
#Bedrooms_ #Bathrooms_ Heating• AS THER or ELECTRtC(Circle One}
Are there any environmentally sensitive areas located on the parcel? �
!f yss,a completed environmental checiclist must accompany peRnit application.
ADDRESS 4. a-1 � S EMAIL
CITY STATE -�t ZIP TELEPHONE 3�0 - �7v-173
� LICENSE#
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE# EXP DATE CITY LICENSE#
:, � ,E ' TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S UCENSE# EXP DATE CITY UCENSE#
'.i'._... _j i a.c.iL �n 1.4t_C- TEtEPHONE l� -�5�i
ADDRESS 5 EMAlL Sa.m ac i l l St.`Vt_c �Cacr►
CITY n�pu.. STATE ZIP QSO FAX
CONTRA `TOR'S LICENSE# �EXP DATE CITY LICENSE# - b 66�S�o • �
Copy of mitigation agreement with Yelm Community Schools, if applicable.
1 heroby cardty thet the above information is corwct and that the constructlon on,and the occupancy snd thQ usa of the
above describod proparty will be in accordance with the laws,rulas and reyulationa of the State of Washinyton and the
Cky ot Yelm.
�
Applica 's Signature Date
Owner!Cantractar/Owner's Agent/Contractor's Agent(Please circle one.)
All permits aro non-transforabla and will explrs if work authorized by such permit is not bagun
within 180 days of issuance,or If work is suspended or abandoned for a period of 180 days
RECEIVEI�
2013
IU5 Yelrn Auenue West (360)458-3 3S
Yetm,WA 98597 (860)458-8 g4,FjfX
mmm.C�.yelm.wa.eta l�Y