20170133 Permit Pkg 03022017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: JERRY /ERIN PRICE
Address: 16228 PRAIRIE CRK LP SE
YELM WA 98597
Property Information:
Site Address: 1R77R PRAIRIE C_RFFK I P SF
Assessor Parcel No.:
Contractor Information:
Name: BLACK DIAMOND ROOFING
Address: DON MORTON
PO BOX 12386
OLYMPIA WA 98512
Contractor License No.: 10092
Project Information:
Project: ROOF
Description of Work:
REROOF
Sq. Ft. per floor:
First
Second
Third
Garage
Basement
Fees:
Item
ROOF
Subdivision:
Permit No.: 20170133
Issue Date: 3/02/2017
(Work must be completed within 180 days)
Phone: 360- 400 -1547
Owner: JERRY PRICE
Lot:
Phone:
Expires: 12/31/2017
Heat Type (Electric, Gas, Other):
Contractor
BLACK DIAMOND ROOFING
TOTAL FEES:
Applican s Affidavit:
certify th t I have read and examined the information contained within the application and know the same
to be tru and correc also certify that the proposed structure is in conformity with all applicable City of
Yelm reg}'lation Iuding those go erning zoning and land subdivision, and in addition, all covenants,
easements and fictions of recor . If applying as a contractor, I further certify that I am currently
registered in the to a of Washin on.
Signature', Dante( 3'2'
Firm
Fees
$ 25.00
$ 25.00
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
m�, 1318elm44
(36C M
RECD': 00261216
3/02/2017 1:59 P
OPEF: co TERM: 001
REF #: 14485
PAID 6Y:
TRAM: 33.0000 6UILDI25 PICAS
20170133 JERRY /ERIN
PRICE,
RAIRIE
16228 P CREEK 5 A CR �c
F'OOF
TENDERED: 25.00 [HECK
F,PPLIED: 25.00 -
[',FIANCE:
°— 0 00
AM 0 35
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 114AP prcL, r1i C('h LoOPSEParcel #:
Subdivision: Lot #: Plan #: Zoning:
New Construction
Plumbing Mechanical
Project
Project Value:
Re -Model Re -Roof / ddition Home Occupation Sign
Mobile / Manufactured Home Placement Other
Building Area (sq. ft) 1s` 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.
eel
BUILDING OWNER NAME: r
ADDRESS EMAIL' 4r riL4C rr1'c Ic✓r1 n't��
CITY STATE ZIP TELE O (all
ARCHITECT /ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL
ADDR S
CITY �
A STA
S LICENSE
DATES // CITY LICENSE #
PLUMBING CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR 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
Applicant's Signature Dat
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 (360) 458 -3835
Yelm, WA 98597 (360) 458 -3144 FAX
www.ci.yelm.wa.us
Low
tom I
Depart ment of Labor and Industries
PO Box 44450
Olympia, WA 98504 -4450
590
BLACK DIAMOND ROOFING INC
PO BOX 12386
OLYMPIA WA 98508
BLACK DIAMOND ROOFING INC
Reg: CC BLACKDR012KE
UBI: 603 - 091 -671
Registered as provided by Law as:
Construction Contractor
(CCOI) - GENERAL
Effective Date: 5/5/1999
Expiration Date: 3/4/2017
CITY OF YELM
BUSINESS LICENSE
BLACK DIAMOND ROOF
IS HEREBY LICENSED TO OPERATE
BLACK DIAMOND ROOF ...
PO BOX 12386 M
OLYMPIA WA 98508~\
This License must be posted in a
conspicuous place at the location.
17 -10092