20170196 Permit Pkg 05232017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458-3144
Applicant:
Name: MICHAEL / MICHELL HOLLINGSWORTH
Address: 9957 JUSTMAN ST SE
YELM WA 98597
Property Information:
Site Address: QQr.7 II ICTMAAI QT CG
Assessor Parcel No.: 78640113700
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: BLACKH1066JL
Project Information:
Project: MECHANICAL
Description of Work: INSTALL AC UNIT
Sq. Ft. per floor: First
Second
Third
Garage
Basement
Fees:
Item
MECHANICAL
Permit No.: 20170196
Issue Date: 5/23/2017
(Work must be completed within 180 days)
Phone: 360- 688 -0994
Owner: MICHAEL HOLLINGSWORTH
Subdivision: TAHOMA TERRA
D�=
Expires: 7/19/2017
Heat Type (Electric, Gas, Other):
Contractor
BLACK HILLS, INC
TOTAL FEES:
Lot: 137
360- 239 -3776
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.
Signature 4Z61.1 ,/ Date5- 2,3-7,O/7
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
Cite of Mm
(36.x) 458 -3244
REC4: 00270056 5/23/2017 1 :27 PM
OPEF: CO TERM: 001
REFS: 18460
PAID BY:
TRAM: 33.0000 BUILDING PERMITS
20170196 29.5(CR
HOLLINGSWORTH, MICHEEL /MIICHELL
9957 JUSTMAN ST SE
MECH 29.5(CR
IE:NDERED: 29.50 (HECK
APPLIED: 29,50_
CHANGE: _ 0.00
From:Black Hills Inc 360 705 8584 05/23/2017 08:11 #974 P.002/004
e?o 1-7 Q/ q &
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: qA, O� c�l !\ 9A(\ ok n 5 Parcel #: -l"; D I, t 99-0 C)
Subdivision: Lot #: Plan #: Zoning:
New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
7 Plumbing °'Mechanical Mobile / Manufactured Home Placement F Other
Project Description/Scope of Work: S�h f"+ I Q `O fN i t_
Project Value: C 3 U '. ; ,
Building Area (sq. ft) 1St Floor 2 "d Floor 3`d 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'OW.NER NAME': 'i C `A6 li I `r' 'G3h1 ,'
ADDRESSES} cill�stt�iY S EMAIL
CITY e9 �, 4 rY� STATES _. ZIP i TELEPHONE S 260 - D i
ARGHITECTIENGINEER 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 TELEPHONE
..........
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR IC $'E r I ? S. 1 TELEPHONES 1� E r9 Q
ADDRESS j DL^ ,S SQ" EMAIL ai
CITY M "ii!`ii Pi 4_STATE FAX ��
CONTRAC OR' LICENSE # fffiC 1 +` �f� �>EXP DATE 1' CITY LICENSE # (k `tG7
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
Cwof m.
A pplicant's Signafure V Date
Owner / Contra'ctor / Owner's Agent / Contractor's Agent (Please circle one.)
V
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,
wu;. WA 98539 (�0), 4,5 C44 FluV
www.ci.yelm.wa.us (fir ��"' [1 S�'`� 1 MAY 2 3 201 i
Bit . ................
From:Black Hills Inc
360 705 8584 05/23/2017 08:11 #974 P.003/004
J
J
J
}
�( l
1
)
j
I
1
)
'!
� �ri ;� }.�a►M Ewa
S � � - �—�-"{