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