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BLD-05-0162 City ofYelm Community Development Department Building Division Phone: (360) 458-8407 Fax: (360) 458-3144 Permit No BLD-05-0162-YL Issue Date 06/08/2005 (Work must be started within 180 days) Receipt No 36961 Applic:ant: Name. Nisqually Valley Moose Phone: Address. City' State: Zip Prop,erty Information: Site Address. 1117 Yelm Avenue West Assessor Parcel No 21744120301 Subdivision. Lot: Contractor Information: Name. Applicant Address. Contact: Phone: City' State. Zip Contractor License No Expires. Business License. Project Information. Project: Nisqually Valley Moose Reroof Description of Work: Tear off and reroof Sq. Ft. per floor' (1st) 0 (2nd) 0 (3rd) 0 Garage 0 Basement 0 Heat Type (Electric, Gas, Other) Fees: Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc Building Permit - Other TOTAL FEES 125.25 $125.25 000 0.00 o 0000 00000 $1 000 Applicant's Affadavit: 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 Yelm regulations including those governing zoning and land subdivision and in addition, all covenants, easements and restrictions of record. If applylhg as a contractor, I futher certify that I am currently registered In the State of Washing 0 ,/ ;;: 1 - ~. ~--==>.. Signature ,r'- .~ _.~, # Sets Of Prints. .-/ FinaUnspection: Date: 0~~1n, r By' x.W'\A. Firm City of Yelm Community Development Department Building Division Phone: (360) 458-8407 Fax: (360) 458-3144 Permit Fees Schedule Permit No BLD-05-0162-YL Applicant: Name. Nisqually Valley Moose Phone: Address City' State. Zip Project Information. Project: Nisqually Valley Moose Reroof Description of Work: Tear off and reroof Site Address. 1117 Yelm Avenue West Assessor Parcel No 21744120301 Fees. Item Acct Code Item Fee Base Amt Unit Fee Unit Rate No Units Unit Desc Building Permit - Other 032 001-322-10-00 125.25 000 000 o 0000 00000 $1,000 TOTAL FEES $125.25 ,---._....., 1:".,..=,.... - . ." I;. ""-.... = . . : . . 0 RECEIPT No.3 6 9 61 RECEiVED ****ONE HUNDPED TWENTY FIVE DOLLARS & ~5 CENTS RECEIVED FROM NISQUALLY VALLEY LODGE POBOX 757 YELH \"1.1\ 98597 360-458-3.381 DATE REC NO 06/08/05 36961 AMOUNT 125.25 CHECI\ REF NO 20771 BUDGETARY HI CHELLE I ..I EUILDING PERMIT BLD-05-016:-YL c c c CITY OF YELM COMMERCIAL BUILDING PERMIT APPLICATION FORM Project Address: J 1/7 !j rLu... A-df' uJ Parcel #. ~ / 7,}, '-1/;1- cf 3 C) I Zoning; Current Use Proposed Use U New Construction U Re-Model I Re-Roof I Tenant Improvement U Plumbing U Mechanical U Fire Prevent/Suppress/Alarm Project Description/Scope of Work: (L.p R () ()4 Project Value: ?? c5~()() I ~() U Other I? f':r< ^' ((, I".... /'.. 0.;", 1 " I It {'">. JIJIi/ 0 " ~ 10 8100S GENERAL CONTRACTOR ADDRESS CITY STATE CONTRACTOR'S LICENSE # PLUMBING CONTRACTOR ADDRESS CllY STATE CONTRACTOR'S LICENSE # MECHANICAL CONTRACTOR ADDRESS CllY STATE CONTRACTOR'S LICENSE # Building Area (sq ft) Parking Garage Building Height ;2.(} I 1st Floor-X-2nd Floor 3n:l Floor_ Are there any environmentally sensitive areas located on the parcel? completed environmental checklist must accompany permit application. If yes, a BUilDING OWNERlTENf.N'T NAME. 1\// S t':(AA CI I \ ADDRESS ) I / 7 ULf Lv1--.... A- U V& EM IL CITY L<--v----. ""STATE (..e/ A- ZIP<?"F0~7 TELEPHONE <360,:, Y 6rV-."'-? ~8/ f:> ARCHITECTIENGINEER ADDRESS I """'T'\' C'T^TC I vii I v I"'.... 710 ..." LICENSE # EMAll T=!..=PHU~!:: TELEPHONE EMAIL FAX EXP DATE CITY LICENSE # ZIP TELEPHONE EMAIL FAX EXP DATE CITY LICENSE # ZIP TELEPHONE EMAIL FAX EXP DATE CITY LICENSE # ZIP Copy of City Mitigation documentation (TFC). 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 a ordance with the laws, rules and regulations of the State of Washington and the City of Yelm. f/r/~~ ;t\gent I Contractor's Agent / Tenant (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 West PO &% 479 Yelm. WA 98597 (360) 458-3835 (360) 458-3144 FAX www.ci.yelm.wa.1UI