20160353 Permit Pkg 10312016A0C Z 'p City of Yelm
�4
4 Community Development Department
Building Division
Phone: (360) 458 -8407
L
Fax: (360) 458 -3144
Applicant:
Name: TERRY COLE
Address: 80 KUPALAOKI LOOP
KIHEI HI 96753
Property Information:
Site Address: Qmn nnNnVAN r_T CF
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKHI066JL
Subdivision:
Permit No.: 20160353
Issue Date: 10/3112016
(Work must be completed within 180 days)
Phone: 360- 456 -3745
Owner: TERRY COLE
Lot:
Phone: 360- 239 -3776
Expires: 3/31/2017
Project Information:
Project: MECHANICAL
Description of Work:
REPLACE GAS FURNANCE
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 State of Washington. �{
Signature %� // Date (J
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
City► of Yelm
(36 0 458 -3244
REW 00248214 10/31/2016 12:06 PM
OPER: CO TERM: 001
REEF : 17715
PAID BY:
TRAM: 33.0000 BUILDING PERMITS
20160353 29.5(CR
COLE, TERRY
9806 DONOVAN CT SE
MECH 29 K CR
TE:NDEREO: 29.50 (HECK.
APPLIED: 29.50-
CHANGE: 0.00
From:Black Hills Inc
360 705 8584 10/31/2016 10:20 #646 P.002/003
X0353
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: ` g -'V t vl'ryo �,��! n ;J % Parcel #: `I 4 u"t 0,00,c
Subdivision:
Lot #: Plan #: Zoning:
New Construction Re -Model / Re -Roof / Addition 7 Home Occupation Sign
Plumbing Mechanical 71 Mobile / Manufactured Home Placement -. Other
Project Description /Scope of Work: u { S n a.cz,
Project Value:
Building Area (sq. ft) 15t Floor 2nd Floor 3`d Floor Garage -2 car 3 car
Covered Patio Covered Porch atio Deck
# Bedrooms_ # Bathrooms_ Heating: G /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.
ADDRESS 0WIX 12 LTM
CITY \11 I AM STA
EMAIL —
P sit TELEPHON
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
I CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR ;SIR _ -1tit , 111.E TELEPHONE 1 0
ADDRESS 003 EMAIL -
CITY T.OSTATE��� ZlP sir FAX .
CONTRAC O S LICENSE # i°cGK1�tGUQ�' EXP DAT ti .1fY LICENSE #'�1�lt1(.�
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 in accordance with the laws, rules and regulations of the State of Washington and the
City Rf Yelm. ---"'�
=e
Lei
A P'o Iff eant q Signature Date
Owner / Contractor / Ow r'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 480 days of issuance, or if work is suspended or abandoned for a periV
OCT -, 12016
105 Yelm Avenue West (3 S S -_3J a ..............
Yelnt. WA 98597 (360) 458 -3144 FAX
www.ei.velm- .wa.us