20160113 Permit Pkg 01222016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Permit No.: 20160113
Issue Date: 1/22/2016
(Work must be completed within 180 days)
Applicant:
Name: JAMES NULL Phone: 253 - 691 -5584
Address: 15313 CHAD DR SE
YELM WA 98597
Property Information:
Site Address: 15313 CHAD DR SE Owner: JAMES NULL
Assessor Parcel No.: 41610019800 Subdivision: CHERRY MEADOWS
Contractor Information:
Lot: 198
Name: BLACK HILLS, INC Phone: 360- 239 -3776
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL Expires: 3/31/2009
Project Information:
Project: MECHANICAL
Description of Work: INSTALL HEAT PUMP AND REPLACE GAS FURNACE
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 W hington.
Signature Date
Z, (
Firm >Itiil %'l—iT�!< 7
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
(3 Q458- 3m44
(360)
REC #: 00220171 1/22/2016 2:41 PM
OPER: CO TERM: 001
REF #: 16860
PAID BY:
TRW 33.0000 BUILDING PERMITS
20160113
NULL, JAMES
15313 CHAD DR S29 5fCR
MECH
TENDERED: 29.50 [HECK
APPLIED: 29.50 -
CHANGE: 0.00
CITY OF YELM 20i(ool t 3
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 16313 Oh-o- 1. 131( Se Parcel #:41 L0 I OU 19 So O
Subdivision:
Lot #: Plan #: Zoning:
❑ New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
❑ Plumbing "- A- Mechanical Mobile / Manufactured Home Placement Other
i
Project Description /Scope of
Project Value: !�p ( C5 I dl
Building Area (sq. ft) 1" Floor 2nd Floor
Covered Patio Covered Porch
# Bedrooms_ # Bathrooms_
-L rkRLCktJ
3rd Floor Garage -2 car 3 car
Patio Deck
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 NAM
ADDRESS fk.-a Y EMAIL
CITY STATE U3 Pr ZI ! TELEPHONE — Lnq I - 15
ARCHITECT /ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERALCONTRACTOR 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 ELEPHONE ' O � -V
ADDRESS 10 _ EMAIL'bWS) '1 & I31LLLALkUMU1C .CCU
CITY STATE_U,5ft ZIPLIV3DI FAX
CONTRA O 'S LICENSE # J 602 EXP DATE CITY LICENSE # 04 - 005�(.e - O
L_ `t(915
Copy of mitigation agreement with Yelm Community Schools, if applicable.
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.
Applicant's Signature Date
Owner I 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.wa.us
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