20170130 Permit Pkg 02172017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: KYLE /IVY STROMGREN
Address: 9011 LEALAN CT SE
YELM WA 98597
Property Information:
Site Address: Qf111 I FAI AN [_T CF
Assessor Parcel No.:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL
Subdivision:
Permit No.: 20170130
Issue Date: 2/17/2017
(Work must be completed within 180 days)
Phone:
Owner: KYLE AND IVY STROMGREN
Lot:
Phone: 360 - 239 -3776
Expires: 3/31/2017
Project Information:
Project: MECHANICAL
Description of Work: REPLACE GAS FURNACE AND INSTALL TANKLESS HOT WATER TANK
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 Sta of Wa ington.
Signature Date ( • 7
Firm ty
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Clt�, of Ni
(361) 458 -3244
RECA`: 00260336 211712017 3 :05 PM
OPER: CO TERM: 001
REF #: 18115
PAID BY:
TRAM: 33.0000 BUILDING PERMITS
20170130 29.5(CR
STROMGREN, KYLE / M
9011 LEALAN CT SE
hIECH 29.5(CR
TENDERED: 29.50 CHECR
APPLIED: 29.50-
CHANGE: _ _ -0,00
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: � 1�1.
ot I M U_ St Parcel #:_3033=_20D
Subdivision:
Lot #: Plan #: Zoning:
2o(W3D
❑ New Construction -- Re -Model / Re -Roof / Addition -- Home Occupation Sign
❑ Plumbing - ;<-Mechanical Mobile / Manufactured Home Placement F Other
Project Description/Scope of Work: AAA, QO S 'C Vt'Y1Z11Le � IY15�W 10111 eSS
Project Value: V C)
Building Area (sq. ft) 1st Floor 2nd 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?
If yes, a completed environmental checklist must accompany permit application.
BUILDING OWNER NAME:
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
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 1 ( tkA TELEPHONE ;)UD 10� X10
ADDRESS W 34�;" A" I;b EMAIL
CITY QMWIIIA STATE WVV ZIP FAX
CONTRACT S LICENSE # <VAk ATE I I Y LICENSE # 1LV
MECHANICAL CONTRACTOR `ate 111 I Y)C TELEPHONE SAD OC • �
ADDRESStQ0 AvX ST EMAIL
CITY MOMVIA STATE )b( ZIP FAX
CONTRAC O 'S LICENSE #&A(.KWDVP to EXP DATn: it 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 f Yelm.
ppll 's Signatur Date
Owner / Contractor wner's Agent / C`ontractor'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
p C 1E7M
FEB 7 617
105 Yelm Avenue West (36 '�8 -3835
Yelm, WA 98597 (3607e =3744rAX -----------
wtvw.ci.yelm.wa.us