20040168
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Permit No
BLD-04-0 168- YL
Issue Date. 10/15/2004
(Work must be started within 180 days)
Receipt No
33497
Applicant:
Name: Mattocks, Greg
Phone:
400-1588
Address: 204 Jefferson
City. Yelm
State: WA Zip
Property Information
Site Address: 204 Jefferson
Assessor Parcel No. 75301400900
Subdivision:
Lot:
Contractor Information:
Name: Applicant
Contact:
Phone:
Address:
City'
State:
Zip.
Contractor License No.
Expires:
Business License.
Project Information
Project: Greg Mattocks
Description of Work: Residential Re-roof
Sq. Ft. per floor' (1st) 1000
(2nd) 400
(3rd) 0
Garage 0
Basement 0
Heat Type (Electric, Gas, Other): OTHER
Fees.
Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc
--------------------------- -------------
Building Permit - Other 25.00 0.00 0.00 o 0000 0.0000 $1,000
TOTAL FEES $25.00
Applicant's Affadavit:
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
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 futher certify that I am currently
registered in the Stat of Washington.
OFFICIAL USE ONLY
# Sets of Prints:
Firm
Date
). /"...s:- ~C)
Final Inspection:
I. ~
Date:~, ;\~~~~L
By' GPPir'
Signature
--
RECEIPT No 33497
RECEIVED
****TWENTY FIVE DOLLARS & 00 CENTS
RECEIVED FROM
MATTOCKS. GREG
204 JEFFERSON AVE NW
YELM. WA 98597
DA.TE REC. NO
10/15/04 33497
,A,MOUNT
REF I\JO
25.00 CHECK
3075
MISCELLANEOUS RECEIPT
JANINE
BLD-04-0168-YL
Applicant:
Name: Mattocks, Greg
Address:
Project Information:
Project: Greg Mattocks
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407 U, '
:t'" ~
1. ) ~~"
Fax: (360) 458-3144
c\1'l Or '{E.LM
City.
Description of Work: Residential Re-roof
Assessor Parcel No. 75301400900
Site Address: 204 Jefferson
Fees.
Item
Building Permit - Other
Acct Code
Item Fee
Base Amt Unit Fee
Permit Fees Schedule
Permit No. BLD-04-0168-YL
"1 ~t-\C\1
Phone.
State:
Zip
032001-322-10-00
2500
0.00
0.00
Unit Rate No. Units Unit Desc
0.0000
o 0000 $1,000
TOTAL FEES
$25.00
\
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o
c
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: d d Lj 7 E F F 1:',5" o-AI AE. ,#t~ Parcel #. '7 r30 I L/ 00 90 D
Subdivision:.....;)OLBEP~ 1...f"T -4t1O/ Lot #. q-l; 10 Zoning; R -
U New Construction ~odel/~~OC;~~dditiOn u Home Occupation Sign
U Plumbing U Mechanical u Mobl e anufactured Home Placement u Other
Project Description/Scope of Work:
./
Project Value: 4t'OcJu
/
Building Area (sq. ft) 1st Floor .I OOD
Basement
f)E - /..?()() F
.
/.../o{~\~=
2nd Floor 1./00
Carport
Deck
Garage
Patio
# Bedrooms_
# Bathrooms_
Heating: GAS/OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel? NO
completed environmental checklist must accompany permit application.
If yes, a
BUILDING OWNER NAME. G-req MA71?Jc/(,
ADDRESS .20<; ..JEFP/i-/?....':;OAP r1I/E A},tJ} EMAIL
CITY STATE w4 ZIP 9'8'~96' TELEPHONE
ARCHITECTIENGINEER
ADDRESS
CITY STATE
LICENSE #
EMAIL
TELEPHONE
ZIP
GENERAL CONTRACTOR
ADDRESS
CITY STATE
CONTRACTOR'S LICENSE #
TELEPHONE
EMAIL
FAX
EXP DATE CITY LICENSE #
ZIP
PLUMBING CONTRACTOR
ADDRESS
CITY STATE
CONTRACTOR'S LICENSE #
TELEPHONE
EMAIL
FAX
EXP DATE CITY LICENSE #
ZIP
MECHANICAL CONTRACTOR
ADDRESS
CITY STATE
CONTRACTOR'S LICENSE #
TELEPHONE
EMAIL
FAX
EXP DATE CITY LICENSE #
ZIP
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.
/0-- 1...5-- (.) '-i
Applican' Si ature Date"
Owner J f ontractor J Owner's Agent J 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 Avenue WeBt
POBo" 479
Yelm, WA 98597
(360) 458-3835
(360) 458-3144 FAX
www.ci.yelm.wa.us
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