20150297 Permit Pkg 09142015City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: MISTI & GARY SHAFFER
Address: 15208 CHAD DR SE
YELM WA 98597
Property Information:
Site Address: 15 ?f1R CHAn nR RF
Permit No.: 20150297
Issue Date: 9114/2015
(Work must be completed within 180 days)
Phone: 253 - 861 -9861
Owner: GARY SHAFFER
Assessor Parcel No.: 41610000200 Subdivision: CHERRY MEADOWS Lot: 2
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKHI066JL
Phone: 360- 239 -3776
Expires: 03/13/2016
Project Information:
Project: MECHANICAL
Description of Work: INSTALL HEAT PUMP. DUCT TEST REQUIRED
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:
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 th to of Washington.
Signature Date
Firm Q1 /Y 1�
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
City of Yelm
(36 ) 458 -3244
REC #: 00206831 9/14/2015 10 :45 AM
OPER: CO TERM: 001
REF#: 16438
PAID BY:
TRAN: 33.0000 BUILDING PERMITS
20150297 29.50CR
SHAFFER, MISTI & GARY
15208 CHAD DR SE
MECH 29.50CR
TENDERED: 29.50 CHECK
APPLIED: 29.50-
CHANGE: 0.00
From :Black Hills Inc 360 705 8584 09/14/2015 07:47 #823 P.002/003
Z) (S6 z�1
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: cJ A �`1 Vi%Cl � Parcel # t� 001 CEO
Subdivision:
Lot #: . Plan #: Zoning:
New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
Plumbing ,'Mechanical Mobile / Manufactured Home Placement Other
jj t
Project Description /Scope of Work: LAIC nn E-L4
Project Value: Ci ka"C fi %
Building Area (sq. ft) 1St Floor 2nd Floor 3rd Floor Garage -2 car 3 car
Covered Patio Covered Porch Patio Deck
# Bedrooms_ # Bathrooms_ Heating: GAS /OTHER o LEECTRIC ircle One)
Are there any environmentally sensitive areas located on the parcel?
If gees, a completed environmental checklist must accompany permit application.
aIJlOW OWNER NAw Aaw
ADDRESS ,s°o r e a EMAIL
CITY rr STATE 'lil3fA ZIP TELEPHONE 63- Ce
4RCHI fECVENGINEER 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 `CONTRACTOR c LnL - TELEPHONE e - 10-3 0
ADDRESS I t�i" =� S EMAIL USGi n C bl0. Kt hg tnC carr
CITY Q YYi_STATE V,5A ZIP '' FAX
CONTRAC ORS LICENSE # Qr_I+Tke� EXP DATE CITY LICENSE #
Copy of mitigation agreement with Yelm Community Schools, if applicable.
105 Yehr, Avenge West (360) 458 -3835
....... ..- .._. ._ .. 60 _. (3 344:FAX .. ...
Yelm, W9 98597.. _. _ ... ...... ---. ) 458 .._.. 1 Y ,.
WWu,.ci.yelm.uia.us
SEP 14 2015
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