20160373 Permit Pkg 11282016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: DEBRA &RICHAR ADDINGTON
Address: 15720 92ND WAY SE
YELM WA 98597
Property Information:
Site Address: I r%77n 07All11 WAV CI=
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKHI066JL
Subdivision:
Permit No.: 20160373
Issue Date: 11/28/2016
(Work must be completed within 180 days)
Phone: 360- 400 -0764
Owner: DEBRA ADDINGTON
Lot:
Phone: 360- 239 -3776
Expires: 3/31/2017
Project Information:
Project: MECHANICAL
Description of Work: INSTALL HEAT PUMP AND REPLACE GAS FURNACE. DUCT 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 ntractor, I further certify that I am currently
registered inFrp State of W�nshington.
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cite of ME
(361) 458 -3244
REC #: 00251153 11/28/2016 12 :05 PM
OPER: CO TERM: 001
REF #: 17787
PAID BY:
TRAM: 33.0000 BUILDING PERMITS
20160373 29.5(CR
ADDINGTON, DEBRA &RICHAR
15720 92ND WAY SE
hIECH 29.5(CR
TENDERED: 29.50 [HECK
APPLIED: 29.50-
CHANGE: 0
From:Black Hills Inc
360 705 8584 11/23/2016 08:38 #791 P.002/003
ov, e 0 3�3
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: I I wow s Parcel #: Gz; C-PDco%
Subdivision: Lot #: J Plan #: Zoning:
New Construction Re -Model / Re -Roof / Addition :7! Home Occupation Sign
D Plumbing Mechanical -_1 Mobile / Manufactured Home Placement L Other
p �
Project Description /Scope of Work:�i�
1
Project Valuer .) Te S 'fi j E' Gc i -mac �,J
Building Area (sq. ft) ls" Floor 2nd Floor
Covered Patio Covered Porch
3`d Floor Garage -2 car 3 car.
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 N ME: "D# -2- >,e�t�l�� -?
ADDRE S 1""b'G:� � EMAIL
CITY _N_ STATE \NJ ZIP 'TELEPHONE
ARCHITECT /ENGINEER LICENSE #
ADDRESS EMAIL
I 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 #
ADDRESS I(; ; CA, qr'i`�
CITY �� f, . i. iA STATE / _ZIP
CONTRACT R' LICENSE #M�It
L
L- EXP DATE I PICITY 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 d scribed property will be�acqordance with the taws, s egutations of the State of Washington and the
City of F=or! \\
Applicant's Signature Dat `
Owner / Contractor /.Ow er's Agent / .Contractor's Agent (Please circle 6ne.)
All permits are non- ` "ferable 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
I NOV MU2ERV
__..__._ __ CO) 2 2016
105 Yelm Avenue 4iest (360) 458 -3835
Yelna W'! '98597 (360)'458 - SAX
www.ci.yelm.wa.us '- ------ - - - - --