20150331 Permit Pkg 11122015City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: MICTORIA COOLIDGE
Address: 15735 95TH CT SE
YELM WA 98597
Property Information:
Site Address: 15735 95TH CT SE
Assessor Parcel No
43390101300 Subdivision:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.:
Expires:
Permit No.: 20150331
Issue Date: 11/12/2015
(Work must be completed within 180 days)
Phone: 360- 458 -9641
Owner: MICTORIA COOLIDGE
Phone: 705 -8590
0 /00 /0000
Lot:
Project Information:
Project: MECHANICAL
Description of Work: INSTALL HEAT PUMP AND REPLACE GAS FURNACE. DUCT LEAKAGE 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:
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 StaAe of Washington.
Signatur Date V(:" V, I I
Firm bo,\c.�
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
(16j o4 8 -9244
(3
REC #: 002129TERM;11 12/2015 12:32 PM
OPER: CO
REF #: 16626
PAID BY:
TRAN; 33,0000 BUILDING PERMITS
20150331
COOLIDGE, MICTORIA
15735 95TH CT S2
MECH 9 50CR
TENDERED: 29.50 CHECK
APPLIED: 29'50_
GRANGE: 0.00
W 5 033
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: \9126 "1s!n c �--E Parcel #: 4 �391DJ CA �1ZQ
Subdivision: Lot #: Plan #: Zoning:
❑ New Construction i Re -Model / Re -Roof / Addition ❑ Home Occupation Sign
❑ Plumbing Mechanical Mobile / Manufactured Home Placement ❑ Other
Project Description /Scope of Work: \-V1;t� 7R.C., 4- 9,'- OaLe GaS hi tnG Le,
Project Value
Building Area (sq. ft) 1St Floor 2nd Floor 3rd Floor Garage -2 car 3 car
Covered Patio Covered Porch Patio Deck
# Bedrooms_ # Bathrooms_ Heatin : GA THER 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: n\CAn.(',Ck f '� \6%
ADDRESS \ 13 ') C.T 13F EMAIL tc ton4� G=h��1 k «m
CITY V)J) STATEW ZIP°1b��ELEPHONE `6
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 CONTRACTOR3\0 is TELEPHONE
ADDRESS 1 . +o AI c Sr EMAIL ramlr�t r Q blt�ct`th IISI nc .tam
CITY 0 STATE\bLik_ZIPq '6Sb 1 FAX
CONTRA TOR'S LICENSE #►�xl�ct\ \CratvJL EXP DATE CITY LICENSE
Copy of mitigation agreement with Yelm Community Schools, 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 of Yelm. .�
A icanYs Sign u e Date
Owner / Contractor / wne s nt / Contractor 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.yelm.tva.us