20150261 Permit Pkg 07242015City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: D.R. /PATRIC CHOJNOWSKI
Address: 15628 92ND WAY SE
YELM WA 98597
Property Information:
Site Address: 15628 92ND WAY SE
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL
Subdivision:
Expires:
Permit No.: 20150261
Issue Date: 7/24/2015
(Work must be completed within 180 days)
Phone: 360- 458 -6827
Owner: TYPE CURRENT OWNER
NAME
Lot:
Phone: 360- 239 -3776
3/31/2009
Project Information:
Project: MECHANICAL
Description of Work: Install Heat Pump and Gas Furnace
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Contractor
D.R. /PATRIC CHOJNOWSKI
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 Date u 2 -11 V
Firm l %6� / l 11�—
Fees
$ 46.50
$ 46.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cifj of Felt
(36 ) 458 -3244
REC#: 00202131
OPER : CO 712412015 3 :20 PM
PER
REF'# : 16268 TERM: 001
PAID BY:
IRAN' 33.0000 BUILDING PERMITS
20150261
CHOJNDWSKI, 46.50CR
15628 92ND OlAY SE
MECH 46.50CR
TENDERED: 46-50
APPLIED: CHECK
46.50-
CHANGE: 0.00
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address:15W ;kS 1:► '1f=l Q C� Parcel #: '
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: i` P.ID1 0 k �& Pl i�-i` 0 �l CkJ:J,
Project Value: ►; UXn6. -L.,
Building Area (sq. ft) 1s` Floor 2nd Floor 3`d Floor Garage -2 car 3 car
Covered Patio Covered Porch 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 NAME: a- ? v:
ADDRESS - U n W C SIC EMAIL
CITY ' STATE UW N ZIP 15`1 -1 TELEPHONE
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 CONTRACTOI
ADDRESS i
CITY ✓ STAT
CONTRAC O 'S LICENSE #
Ut- L LtS UXICTELEPHONE -
EMAIL
EXP DA
Copy of mitigation agreement with Yelm Commu
CITY LICENSE #
i`t t `j
/ S hoots, 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 oLXQlm.
Applicant'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 period of 180 days
105 Yelm Avenue West (360) 458 -3835
Yelm, WA 98597 (360) 458 -3144 FAX
www.ci.velm.ma.us