20140139 Permit Pkg 03312014 �oF t"�A,�� City of Yelm Permit ►vo.: 20140139
� � Community Development Department Issue Date: 3/31/2014
p, sn (Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
YELM
'"`.`�" Fax: (360)458-3144
Applicant:
Name: DOMINIC RIVAS Phone: 253-279-0102
Address: 513 EMERALD LN SE
RAINIER WA 98576
Property Information:
site Address: 16643 100TH WAY SE owner: DOM�N�C RIVAs
Assessor Parcel No.: 51540202100 Subdivision: Lot:
Contractor Information:
Name: DOMINIC RIVAS Phone:
Address:
513 EMERALD LN SE
RAINIER WA 98576
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: RESIDENTIAL ADDITION
Description of Work: INTERIOR ADDITION. ADDITION OF A SECOND BATHROOM
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
BUILDING DOMINIC RIVAS $ 164.36
TOTAL FEES: $ 164.36
ApplicanYs Affidavit: OFFICIAL USE ONLY
I ceRify 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 t s}liDgton.
---____ 2 3` 'c ' Date:
Signature Date J ��
By:
Firm
�lt� ���e�mo2
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REC#: UU156419 3I��/2014 12:14 NM
OPER: CO TERM; QU1
R�,F#: �1501
1�RAN: 33��1000 ���1"n 164.36CR�TS
20140139
R�VAS, DOMINIC
1664;3 100TN W�j�4E��CR
BLDG
TENDEREG: 164.36 CN'�CK
APPLIED� 1�4.36-
CHANGF:
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CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address:��y� ��'� �iI�A.W J� Parcel#: J IS�{026Z100
Subdivision: Lot#: Plan#: Zoning: l�c,ra� �[Si(�t�1�►��
❑ New Construction � Re-Model/ Re-Roof/Addition ❑ Home Occupation Sign
�, Plumbing ❑ Mechanical ❑ Mobile/ Manufactured Home Placement ❑ Other
Project Description/Scope of Work: I�r�i�o�n r� ��d �7a�lireorn'Ti��U'ior nef C1C�cr�cr �(���a�
Project Value:�_`���00 Oc�
Building Area (sq. ft) 1St Floor�� 2"d Floor 3�d Floor Garage-2 car 3 car
Covered Patio Covered Porch Patio Deck
# Bedrooms� # Bathrooms 1 Heating: GAS/OTHER o LECTRI (Circle One)
Are there any environmentally sensitive areas located on the parcel? �/ O�_
If yes, a completed environmentat checklist must accompany permit application.
BUILDING OWNER NAME: ;nic,
ADDRESS r EMAIL _ �� Z ati o•
CITY Q.,a;�r�itr STATE�_ZIP q S�'�(a TELEPHO �S�2�9—ol�Z _
ARCHITECT/ENGINEER S�I� 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.
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.
�
' ant's Signature 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
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� M�R 1 �' 2014
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105 Yelm Auenue West (360)4 8-3835
Yelm, WA 98597 (360)43�-3.14QFA� — - -----
www.ci.yelm.wa.us
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