20160189 Permit Pkg 04132016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: MILTON W BUTLER
Address: 14630 BERRY VLY RD SE
YELM WA 98597
Property Information:
Site Address: 109 MOSMAN AVE SE
Assessor Parcel No.: 22719331300 Subdivision:
Contractor Information:
Name: MILTON W BUTLER
Address:
14630 BERRY VLY RD SE
YELM WA 98597
Contractor License No.: Expires
Permit No.: 20160189
Issue Date: 4113/2016
(Work must be completed within 180 days)
Phone: 360- 458 -5420
Owner: MILTON W BUTLER
Phone:
1 I1 1111
Project Information:
Project: MECHANICAL
Description of Work:
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Lot:
Fees:
Item Contractor Fees
MECHANICAL MILTON W BUTLER $ 42.50
TOTAL FEES: $ 42.50
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 Washington.
Signature jr Date �13 r (�
Firm
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
r
City of Mi
(36 ) 458 -3244
REC #: 00228138 4/13/2016 8:12 AM
OPER: CO TERM: 001
REF #:
PAID BY:
ACCT #: XXXXXXXXXXXXXXXXXXX
AUTH #: 081248
TRAN #: 000000000662
TRAN: 33,0000 BUILDING PERMITS
20160189 42.56CR
BUTLER, MILTON W
109 MOSMAN AVE SE
MECH 42.56CR
TENDERED: 42.50 CREDIT CARD
APPLIED: 42,50-
CHANGE: 0.00
..►
l�,C
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: � 0!J N S— -+- A v e 3 t Parcel #:
Subdivision: Lot #: Plan #: Zoning:
New Construction i Re -Model / Re -Roof / Addition Home Occupation Sign
Plumbing Mechanical Mobile / Manufactured Home Placement F Other
Project Description /Scope of
Project Value:
Building Area (sq. ft) 1St Floor 2nd Floor Garage Deck
Basement Carport Patio
# Bedrooms_ # Bathrooms_ Heating: GAS /OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel?
/f yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME: in % w .B A 1Fti-
ADDRESS )0 1 1YLo,S ry,,&� EMAIL
CITY V, � STATE A2 A ZIP a k C ,1 TELEPHONE `I SC
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 CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # 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.
23
Applicant's Signature Da e
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.yelm.wa.us