20160403 Permit Pkg 12092016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: SUE GORE
Address: P.O. BOX 4027
TENINO WA 98589
Property Information:
Site Address: 153(18 RFRRY VAI I FY nR SF
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL
Subdivision:
Permit No.: 20160403
Issue Date: 12/09/2016
(Work must be completed within 180 days)
Phone: 360- 264 -5931
Owner: SUE GORE
Lot:
Phone: 360 - 239 -3776
Expires: 3/31/2017
Project Information:
Project: MECHANICAL
Description of Work: 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 a contractor, I further certify that I am currently
registered in the State of Washington.
r
�-^-
Signature 1� /y1Y` Date i
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cite of Yelm
(36 i) 458 -3244
RECK 00252282 12/09/2016 11:57 AM
OPER: CO TERM: 001
REFS' : 17857
PAID BY:
TRAM: 33.0000 BUILDING PERMITS
20160403 290CR
GORE, SUE
15306 BERRY VALLEY CR SE.
MECH 29.5CCR
TENDERED: 29.50 CHECK.
APPLIED: 29.50 -
CHANGE: 0.00
From:Black Hills Inc 360 705 8584 12/09/2016 10.43 #910 P.002/003
ZVI Lt o-5
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: J;�q21no " &, (�`i''im� VA I lie i p r Parcel #: 41_ 6117l 10 00 0 WI,00
Subdivision: Lot #: Plan #: Zoning:
n New Construction Re -Model / Re -Roof / Addition L Home Occupation Sign
F1 Plumbing mechanical ❑ Mobile / Manufactured Home Placement n Other
Project Description` /Scope of Work: _x a o,c$ s kwn a c� tn1
Project Value:��
Building Area (sq. ft) list Floor 2"d Floor 3`d Floor Garage -2 car 3 car
Covered Patio Covered Porch i'' Deck
# Bedrooms # Bathrooms_ Heatin GAS THER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on parcel?
If yes, a completed environmental checklist must accompany permit application.
B(AbIN&OWNER NAME': f , 6-tY1
ADDREB' d I W 17� EMAIL
CITY STAT ZIP TELEPHONE ':Z,',O, 2CQ`1-_ E-`Ia
Akc!I CT/ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL. CONTRACTOR TELEPHONE
AbbRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PL7MBING CbN'fRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR l',JL t1 rj% , ? TELEPHONE UQ, a , %
DDR �
AESS ':T��t^' i EMAIL
CITY "'" Um 0 ? A STATE ZIP � FAX
CONTRA OR'S LICENSE # 'FNWJ� ,i-i,l J j ) ✓ EXP DATtZLi2dTY LICENSE # W'4�
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.
1
Applic is Ion re Date
Owner / Contract / Owner's Agent / Contractor's Agent (Please circle one.)
,q
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 da s S
M 09 01C G 2010
105 Yelm Avenue West (36 -3835
Yelm, WA 98597 (3611?i"'�•��������
www.ci.ye1M.ma.us