20170295 Permit Pkg 08212017City of Yelm
Community Development Department
Building Division
Phone: (360) 458 -8407
Fax: (360) 458-3144
Applicant:
Name: JOHN & TIFFANY ROSS
Address: 9121 CARYS ST SE
YELM WA 98597
Property Information:
Site Address: A191 (_ARMS ST AF
Assessor Parcel No.: 63520005400
Contractor Information:
Name: BLACK HILLS, INC
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: 1610091
Permit No.: 20170295
Issue Date: 8/21/2017
(Work must be completed within 180 days)
Phone: 770 - 490 -3596
Owner: JOHN ROSS
Subdivision: MT SHADOW
Lot: 54
Phone: 360- 239 -3776
Expires: 12/31/2017
Project Information:
Project: MECHANICAL
Description of Work: INSTALL HEAT PUMP AND REPLACE GAS FURNACE
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 State of Washington.
Signature %S Gc %�- Date 0/a l�l
Firm
Fees
$ 29.50
$ 29.50
OFFICIAL USE ONLY
# Sets of Prints:
Final Inspection:
Date:
By:
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(35[) 458-3244
REW 00279302 8/21/2017 1:22 PM
OPBP CO TERM: 001
REFh: 18813
PAIG 8Y:
TRAW 310000 BUILDING P[HMD&
20170295 290CR
ROSS, JOHN & TIFFAN\
9121 CARY8 3T SE
NECH 29.5(CR
lENDERED: 29.50 (HECK
APPLIED: 29.50-
Zo i-P2R 5"
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: 9121 LrHs S�St Parcel #:(" !! 000eoo
Subdivision:
Lot #: Plan #: Zoning:
New Construction ❑ Re -Model / Re -Roof / Addition Home Occupation Sign
Plumbing Mechanical - Mobile / Manufactured Home Placement Other
Project Description /Scope(( of Work: %L OLL
Project Value: Lq
Building Area (sq. ft) 1St Floor 2"d 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 WNE NAME:
ADDRESS EMAIL
CITY U[ IY) S ATE WR ZIP TELEPHONE U - -
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 #
MECHANICAL CONTRACTOR Q TELEPHONE LULU- JQ1J ZS'D"l
ADDRESS 1004� s ti EMAIL San 6D bla L l S tytC -"m
CITY STATE LON ZIPq �FAX
CONTRAG-YOR S LICENSE # EXP DATE CITY LICENSE #Qq-
L -71 ICI I-:�i
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 aIm. �2i
Applicant'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, 97A 98597
www.ci.yelm.w¢.us
(360) 458 -3835
(360) 458 -3144 FAX