20170266 Permit Pkg 07252017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458 -3144
Applicant:
Name: MICHAEL /ANNETT STEWARD
Address: 10434 BRIGHTON ST SE
YELM WA 98597
Property Information:
Site Address: 1fld�d RRlr,l -ITON RT RF
Assessor Parcel No.: 65080009000 Subdivision:
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: 1610091
Permit No.: 20170266
Issue Date: 7/25/2017
(Work must be completed within 180 days)
Phone:
Owner: ANNETT STEWARD
Lot:
Phone: 360- 239 -3776
Expires: 12/31/2017
Project Information:
Project: MECHANICAL
Description of Work: REPLACE GAS FURNACE. DUCT TEST REQUIRED, COPY TO CITY OF YELM
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:
1 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.
-7 a
Signature .1 � 11— 4 4` Date // 5 ���
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
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From:Black Hills Inc
360 705 8584 07/2512077 09:77 #203 P.002/003
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address:I~ Parcel #:
Subdivision: Lot #: Plan #: Zoning:
New Construction Re -Model / Re -Roof / Addition Home Occupation Sign
Plumbing Qse hanjcal•-' Mobile / Manufactured Home Placement Other
Project Description /Scope of Work: L_ Qc � y_01 Ce.
Project Value:
Building Area (sq. ft) 1" Floor 2nd Floor.
Covered Patio Covered Porch
# Bedrooms_ # Bathrooms_
3`d Floor Garage -2 car
Patio Deck
3 car
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.
BUILDIN"OWNER NAME:
G'
ADDRESS Y-- `Q t !j� EMAIL
CITY STA c \/14A—ZIP ( TELEPHONE
-- e
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 TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICALCONTRACTOR JCA :-_t- 3?;Ia. tYIC TELEPHONE
ADDRESS tQOa ✓M EMAIL
CITY C STATE yya ZIPQIQJSO f FAX
CONTRAC'fOR"S LICENSE # EXP DATE CITY LICENSE # i
Copy of mitigation
elm 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 Ye lm.
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t% t I�
Applicant's Signatt, r Date -
Owner f Contractor�4- wner'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
W LIE
2017
105 Yelm Avenue West BY : (360) 458 -3835
Yelm, WA 98597 -- _-_--e_-- "G&).4i"l44 FAX
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