20150197 Permit Pkg 05202015City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: M J MITZNER TRUST
Address: P.O. BOX 238
YELM WA 98597
Property Information:
Site Address: Rm i LANAI Rn SE
Assessor Parcel No.: Subdivision:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: 10091
Permit No.: 20150197
Issue Date: 5/20/2015
(Work must be completed within 180 days)
Phone: 360- 400 -1463
Owner: MJ MITZNER
Lot:
Phone:
Expires: 12/31/2015
Project Information:
Project: MECHANICAL
Description of Work: INSTALL DUCTLESS HEAT PUMP
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Contractor
BLACK HILLS, INC
TOTAL FEES:
Applicant's Affidavit:
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 further certify that I am currently
registered in the State of Washington. /�_
Signature " 1 = Date J J10
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Citj of Yelm
(36 ) 458 -3244
REC #: 00196090
OPER: CO TERM:
REF #: 16052
PAID BY:
5/20/2015 11 :47 AM
001
IRAN: 33.0000 BUILDING PERMITS
20150197 29.50CR
MITZNER TRUST, M J
8511 CANAL RD SE
MECH 29.50CR
TENDERED: 29.50 CHECK
APPLIED: 29.50-
CHANGE: 0.00
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 45I I t 0-nd—� ka Se Parcel #: as 01 (1? 3 1 O a00
Subdivision: Lot #: Plan #: Zoning:
❑ New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
❑ Plumbing Mechanical Mobile / Manufactured Home Placement Other
Project Description /Scope of Work: G� &L f1UlX.p
Project Value: 1 oc�n . ' 00 0
Building Area (sq. ft) 15' Floor 2 "d Floor.
Covered Patio Covered Porch
3" Floor Garage -2 car 3 car
Patio Deck
# Bedrooms_ # Bathrooms_ Heating: GAS /OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel?
If yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER N, ,,ME:
ADDRESS S EMAIL
CITY STATE LLTIA- ZIP TELEPHONE —4Od — I L4 U6
ARCHITECT /ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTOR 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 CONTRACT(
ADDRESS IQU; 'I54t�
CITYSTA
CONTRACTOR'S LICENSE
F�
TELEPHONE
EMAIL
E.XP DATE jj iCITY LICENSE #
Copy of mitigation agreement with Yelm Comm rlify S ools, if applicable.
1 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.
lciYw�, him J�-'
App Icl ant's Signature Date
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 eriod of 180 days_
MAY 2 0 2015
105 Yelm Avenue West (360) 458 -3835
Yelm, WA 98597 (360) 458 -3144 FAX
www.ci.velm.wa.us
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