20160408 Permit Pkg 12222016City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: TOM LUEY
Address: 309 JEFFERSON AVE NE
YELM WA 98597
Property Information:
Site Address: anq AVF NF
Assessor Parcel No.: 64420900800 Subdivision:
Contractor Information:
Name: TOM LUEY
Address:
309 JEFFERSON AVE NE
YELM WA 98597
Contractor License No.:
Project Information:
Project: MECHANICAL
Description of Work:
REPLACE GAS FURNACE
Sq. Ft. per floor:
First
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Permit No.: 20160408
Issue Date: 12/22/2016
(Work must be completed within 180 days)
Phone: 360- 451 -1932
Owner: TOM LUEY
Lot:
Phone:
Expires: 0 /00 /0000
Heat Type (Electric, Gas, Other):
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. I applyin ontractor, I further certify that I am currently
registered in the State of Washi
Signature Date
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cite of Y�lm
(36 �; 458 -3244
RECD`: 00253825 1212212016 1 :32 PM
OPER: CO TERM: 001
REFS': 17897
PAID BY:
TRAM: 33,0000 BUILDING PERMII3
20160408 29.5(CR
LUEY, TOM
309 JEFFERSON AVE NE
MECH 29,5(CR
TENDERED: 29.50 CHECK
APPLIED: 29.50-
CHANGE: 0.00
From.Black Hills Inc 360 705 8584 12/22/2016 08.47 #P011 P.002/003
CITY OF YELM
��,�� RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: �� 2l;'ii . 1 � / Parcel #: C20`20
�_..
Subdivision: Lot #: Plan #: Zoning:
New Construction - Re -Model / Re -Roof / Addition FLI Home Occupation Sign
Plumbing XMechanical - Mobile / Manufactured Home Placement F Other
Project Description /Scope of Work: �(Iry i.a Vyncl
� ul
Project Value:
Building Area (sq. ft) 1$' Floor 2 l Floor 3rd 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?
ff yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME:
ADDR S`� M " t1i i EMAIL
CITY E STAT ZIP�'tY3 °t I TELEPHONE
ARCH ITECTIENGINEER LICENSE #
...................... .
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CON7"RAC'T'OR TELEPHONE T
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PLUNGING CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR GI " kaLTELEPHONE ,O
ADDRESS '" ? 3 EMAIL
CITY 1G'1 STATE A ZIP FAX ; i a
CONTRACTOR'S LICENSE # 1 3 ",fKfJIiQ�f9)L_EXP DATES Adfy LICENSE # Itsi��
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.
Ap li6ant's Signa' use V Datdd-
Owner / Contract r / 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 peri I (V 1�
105 Yelm Avenue West (3 8 -3835
Yelm, WA 98599 (3 ) V`5- 3777'rAr ... annumn
www.ci.ye1rn.u,a.us