20170116 Permit Pkg 01242017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: ROLAND SMITH
Address: P.O. BOX 171
YELM WA 98597
Property Information:
Site Address: 1 rd7- 1 n7TH I P SF
Assessor Parcel No.: 62310002500
Contractor Information:
Name: ROLAND SMITH
Address:
P.O. BOX 171
YELM WA 98597
Contractor License No.:
Permit No.: 20170116
Issue Date: 1/24/2017
(Work must be completed within 180 days)
Phone: 360- 400 -0765
Owner: ROLAND SMITH
Subdivision:
Phone:
Expires: 0 /00 /0000
Project Information:
Project: MECHANICAL
Description of Work: INSTALL NEW NATURAL GAS WATER HEATER
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Contractor
ROLAND SMITH
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 anA re rictio of record. If applying as a contractor, I further certify that I am currently
registered in St t in ton.
Signature Date /— Z q- /%
Firm
Lot:
Fees
$ 36.00
$ 36.00
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cite of Mm
(36 0 458 -3244
REC#: 00257195 1/24/2017 2:48 PM
OPER: CO TERM: 001
REFA' :
PAID BY:
ACCT #: XXXXXXXXXXXXXXXXXXX
AUTH #: 999662
TRAN #: 000000004036
TYPE:: PURCHASE
TRAM: 33.0000 BUILDING PERMIT'S
20170116 36.0(CR
SMITH, ROLAND
15425 107TH LP SE
MECH 36.0(CR
TENDERED: 36.00 CREDIT CARD
APPLIED: 36.00-
CHANGE: 0.00
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 4/1 /d 7 Lt L p. S l Parcel #:
Subdivision: Lot #: Plan #: Zoning: _
New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
4f Plumbing Mechanical Mobile / Manufactured Home Placement Other
Project Description /Scope of Work: 7t? S k +!1 / flee PC iL" ( (16
Project Value. i -) V _'
Building Area (sq.
ft) 1s2 Floor 2nd Floor
3 -d Floor
Garage -2 car 3 car
Covered Patio
Covered Porch
Patio
Deck
# Bedrooms_
# Bathrooms_
Heatin : GA
OTHER or ELECTRIC (Circle One)
Are there any environmentally sensitive areas located on the parcel? Vn k4s), 1
If yes, a completed environmental checklist must accompany permit application.
WADING MINER NAME:
ADDRESS /S N!S` /O 7 ra t e �, . EMAIL
CITY ye )r. STATE _ZIP 2 f S_ 75 TELEPHONE 3c.o -.,,Ic11 J
CT/ENGINEE - -- LICENSE # --
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
ENERALCONTRACTOR TELEPHONE
ADDRESS_ EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PJJ)1MBING QQUUWTOR _ T-7
ADDRESS y'7 /-r tc, � 1�1
CITY 1,41, STATE_
CONTRACT R'S LICENSE # 1z
n�J fu,a h,nc �TELEPHONE 3( ,) "q5/- /L/ 1 c _
/CJ. S f EMAIL Tbhv4.s teen CoLpf r- P (- ►1i,1 -.Ar t-
w>4 ZIP 5'fcS 03 FAX_�o-
'hA.NSYib&P EXP DATEy&JCITY LICENSE # 17 'la 3K1
" 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 YeI -'3
Applican s Signature Date
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
Yelm, WA 98597
www.ci.yelm.wa.us
(360) 458 -3835
(360) 458 -3144 FAX