20180233 203 Mosman Ave Mech ;of" l City of Yeim Permit No.: 20180233
1 Community Development Department Issue Date: 6/19/2018
(Work must be completed within 180 days)
Building Division
Phone:(360)458-8407
'•11111 Fax: (360)458-3144
Applicant:
Name: BLACK HILLS, INC Phone: 360-239-3776
Address: 1003 85TH AVE SE
OLYMPIA WA 98501
Property Information:
Site Address: 203 MOSMAN AVE SE Owner: WOLF JOANNE
Assessor Parcel No.: Subdivision: Lot:
Contractor Information:
Name: BLACK HILLS, INC Phone:
Address:
1003 85TH AVE SE
OLYMPIA WA 98501
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: PLUMBING
Description of Work: REPLACE 50 GALLON GAS WATER HEATER
Sq. Ft.per floor: First Heat Type(Electric,Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
PLUMBING BLACK HILLS, INC $ 27.00
TOTAL FEES: S 27.00
Applicant's Affidavit: f OFFICIAL USE ONLY
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 #Sets of Prints
YeIm 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 Final Inspection:
registered in the State of Washington.
Signature; ,"c /A-4---- �Z - Date 6//V6)04 Date:
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GEI�RGE.'.
CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM 1
Project Address:203 S 1 f l,X P �� Parcel#: x-21 (61 �✓2 2J 00
Subdivision: Lot#: Plan #: Zoning:
New Construction Re-Model/ Re-Roof/Addition Home Occupation Sign
lumbing Mechanical Mobile I Manufactured Home Placement Other,I
Project Description/Scope of Work: A € 'D @Ca. � W Cil C v &w(
Project Value: �--C
Building Area (sq. ft) 15t 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 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 CO T' ,CTOR i I . , L TELEPHONE Ai) -1()r Ste(
ADDRESS Lb it �t� b. EMAIL
CITY 1 ai ) STATE , ; ZIP 119/14 FAX (T
CONTRA O' S LICENSE# !!Rii.tea Il..! L.-XP DATES 1 -017Y LICENSE# /.0
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 of Yelm.
41111 1
I nt's S • ature Date
Owner/ Cont :ctor/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.ciyelm.wa.us