20160136 Permit Pkg 02242016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: BLACK HILLS, INC
Address: 1003 85TH AVE SE
OLYMPIA WA 98501
Property Information:
Site Address: QRlr% r)r1K1r%X1AK1 f`T C=
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: 10091
Subdivision:
Permit No.: 20160136
Issue Date: 2/24/2016
(Work must be completed within 180 days)
Phone: 360- 239 -3776
Owner: BOB SOWERS
Phone:
Expires: 12/31/2015
Project Information:
Project: MECHANICAL
Description of Work: REPLACE GAS FURNACE. DUCK LEAKAGE TEST
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 St to of Washington. �
Signature Date c`
�' -/ V
Firm
Lot:
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
c6tj of Yelm
458-3244
REC #: 00223719
OPER: co 212
4/2016
REF #; TERM: 001
BY:
PAID 1: 71
2:01 PM
IRAN: 33,0000
20160136 BUILDING PERMITS
BLACK HILLS 29 5GCR
MECH
9615 DONOVAI C N SE
TENDERED; 29, 5(rCR
APPLIED: 29.50 CHECK
29.50 -
CHANGE;
0.00
e&MA916
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project AddressG1001 -Do n6yan VC" Sf- Parcel #: Sguqona2mo
Subdivision:
Lot #: Plan #: Zoning:
❑ New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
[I Plumbing r, 411 echanical Mobile / Manufactured Home PI cement 7 Other
Project Description /Scope of Work:
Project Value: Ck
Building Area (sq. ft) 1" Floor 2nd Floor 3`d Floor Garage -2 car 3 car,
Covered Patio Covered Porch Patio Deck
# Bedrooms_ # Bathrooms_ Heati : GAS/ 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 WNER NAME:
ADDRESS EMAIL
CITY OtDjM STATE( ZIP TELEPHONE 3Lo-O- 96 1 -
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 CONTRACCT,01
AD P R SS LV0J
CITY CL� STAT
CONTRAC OR' LICENSE #
Copy of
TELEPH
EMAIL �
_ EXP DATE
L_ 6
Yelm Commu lb
CITY LICENSE #
Is, 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 o elm.
App (cant'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.wa.us