20160212 Permit Pkg 05062016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Permit No.: 201 60212
Issue Date: 5106/2016
(Work must be completed within 180 days)
Applicant:
Name: BEN / TONI SADLOWSKI Phone: 360- 400 -1617
Address: 10440 GROVE RD SE
YELM WA 98597
Property Information:
Site Address: 4nAAn GROVE RD SE Owner: BEN SADLOWSKI
Assessor Parcel No.: 64303100704 Subdivision: N/A
Contractor Information:
Name: BLACK HILLS, INC Phone:
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: 10091 Expires: 12/31/2016
Project Information:
Project: MECHANICAL
Description of Work: REPLACE HEAT PUMP AND AIR HANDLER
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 S at o ashi to
Lot: D
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
City of Mm
(36 ) 458 -3244
REC #: 00230415 5/06/2016 1:26 PM
OPER: CO TERM: 001
REF #: 17196
PAID BY:
TRAN: 33.0000 BUILDING PERMITS
20160212 29.50CR
SADLOWSKI, BEN / TONI
10440 GROVE RD SE
MECH 29.56CR
TENDERED: 29.50 (HECK
APPLIED: 29.50-
CHANGE: 0.00
From:Black Hills Inc
360 705 8584 05106/2016 08:45 #521 P.001 /001
CITY OF YELM
RESIDENTIAL ,BUILDING PERMIT APPLICATION FORM
Project Address �4�Q �Q Q6 Sf Parcel #: LQQ50 _5i o6-? 04
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: IJU °4- 00—r � Ka-r\( 'I LY-
Project Value: I I 00
Building Area (sq. ft) 1st 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 d
ADDRESS VqtEP6 1(04L40 brCKE EMAIL
CITY 111 STATE WR ZIP "2 TELEPHONE -AAe0 ° -ISM -
ARCHITEGTIENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL;CONTRACTOR TELEPHONE
ADDRESS
EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PLUMBING CU TRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTO c, IC LEPHONE
ADDRESS i 00 7iG�'4,h (-kiQ b f EMAIL
CITY 4n ca STATE'I,Pt ZIP � FAX _
CONTRAC -TOR'S LICENSE #bLACV J4 b41. i EXP DATE CITY LICENSE # C)
"Z 1 f1 I I '7 f
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
Applicant's Signature Date l
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 i
6
105 Yelm Avenue West
Yelm, WA 98597
u)wu%ci.yelrn.u,¢. us
( 0) 458 -3835