20140298 Permit Pkg 12182014 'f'`�o� TH�A,�� City of Yelm Permit►vo.: 20140298
�
� �� Community Development Department Issue Date: 12/18/2014
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
EL
'".�"'""°" Fax: (360)458-3144
Applicant:
Name: MATTHEW IDZIAK Phone: 360-339-0611
Address: 117 MOSMAN AVE SE
YELM WA 98597
Property Information:
site Address: 117 MOSMAN AVE SE Owner: MATTHEW IDZIAK
Assessor Parcel No.: 22719331500 Subdivision: Lot:
Contractor Information:
Name: MATTHEW IDZIAK Phone:
Address:
117 MOSMAN AVE SE
YELM WA 98597
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: PLUMBING
Description of Work: CONNECTING MAIN WATER LINE FROM METER TO HOUSE. CONTACT YELM PUBLIC
WORKS BEFORE COVERING
Fees:
Item Contractor Fees
PLUMBING A PLUS SERVICES $ 20.00
TOTAL FEES: $ 20.00
Applicant's 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 Washington.
Signature Date �2 ' )� � l`( Date:
Firm S'� � �rV i ��� � 1 V� BY'
_
. ,�
Cit� of Y�lm
(36 ) 458-8402
REC#: OQ181253 12/18J2014 1 :57 PM
OPER: CO TERM: 001
REF#: 334b0
TRAN: 33.0000 BUILDING PERMITS
20140298 20.00CR
IDZIAK, MATTHE4�
117 MOSMAN AVE SE
PL 20,OOCR
TENDERED: 20.00 CHECK
APPLIED: 20.00-
CHANGE: 0.00
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CITY OF YELM
RESIDENTIAL BUILDiNG PERMIT APPLICATION FORM
Project Address: � �^1 /�US ✓✓�u.In /l V� S� Parcel#:
Subdivision: Lot#: Plan#: Zoning:
�7 New Construction i: Re-Model/Re-Roof/Addition ❑ Home Occupation Sign
t�Yf'lumbing �-� Mechanical ❑ Mobile/Manufactured Home Placement �� Other
Project Description/Scope of Work:(�✓►+ne����.��, Mu�^ �u� ��n-'z •�vO^^ v�-�'�"U `'�-s, �!°�,'�
Project Value:
Building Area(sq.ft) 1S' Floor 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?
lf yes, a completed environmentai checklist must accompany permit application.
BUILDING OWNER NAME:
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
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 �} ; �ce ' ./1'�91� A�' ELEPHONE 3Ga- �/9� ' Z9�'�
ADDRESS �Z Z S P���F�"� f+ve s� EMAIL
CITY L�L�:c STATE LJ,� ZIP 9�'�SQ 3 FAX :>6 0 't� l - 1� fl
CONTRACTO 'S LICENSE# EXP DATE CITY LICENSE#
MECHANICAL CONTRACTOR TELEPHONE
ADDRESS EMAI�
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 Yel .
�� � Z - %� � r �j
A anYs Signature Date
O ner/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 Avenc�e West (360)458-3835
Yelm,WA 98597 (360)458-3144 FAX
www.ci.yelm.wa.us