20080259 Permit Pkg 090408~~pF THFp~~ City of Yelm
~p Community Development Department
o, K~
Building Division
Phone: (360)458-8407
I, Fax: (380)458-3144
Applicant:
Name: Baughn, Ron
Address: 1416 Crystal Springs Road City: Yelm
Property Information:
Site Address: 1416 Crystal Springs Road
Assessor Parcel No. 22718310102 Subdivision:
Contractor Information:
Name: Chets's House Moving Contact:
Address: 16420 48th Ave. E City: Tacoma
Contractor License No: Expires:
Project: Bauglr Foundation
Description of Work: Move DOT House from Canal Estates
Permit No: BLD-08-0259-YL
Issue Date: 09/04/2008
(Work must be started within 180 days)
Receipt No: 56058
Phone: 253-224-7661
State: WA Zip 98597
- _ -~~:
Lot:
Phone: 253-535-4558
State: WA Zip: 98446
Business License:
Sq. Ft. per Floor: (1st) 0 (2nd) 0 (3rd) 0 Garage 0 Basement 0
Heat Type (Electric, Gas, Other): OTHER
Fees:
Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc
Building Permit -Other 307.25 0.00 0.00 0.0000 0.0000 $1,000
TOTAL FEES: $307.25
Applicant's Affadavit:
I certify that I have read and examined the information contained within the application and know the same OFFIC
to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of # Sets 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 futher certify that I am currently
registered in the State of Washington. Final Ins
Signature ) L ~^ Date ~ j' - ~ __
. ~ Date:
~~
Firm
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360)458-3144
Applicant:
Name: Baughn, Ron
Address: 1416 Crystal Springs Road City: Yelm
Project Information:
Project: Bauglr Foundation
Description of Work: Move DOT House from Canal Estates
Permit Fees Schedule
Permit No: BLD-08-0259-YL
Phone: 253-224-7661
State: WA Zip 98597
Site Address. 1416 Crystal Springs Road Assessor Parcel No. 22718310102
Fees:
Item Acct Code Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc
Building Permit-Other 032 001-322-10-00 307.25 0.00 0.00 0.0000 0.0000 $1,000
TOTAL FEES: $307.25
~ J.~~~(% ~~y
CITY OF
YELM
P.O. Box 479
Yelm, WA 98597
360-458-3244
RECEIVED
RECEIPT No. 5 6 0 5 8
'"***THREE HUNDRED SEVEN DOLLARS & 25 CENTS
RECEIVED FROM DATE REC. NO. AMOUNT REF. NO.
RONALD BAUGHN 09/04/08 56058 307.25 CHECK 1012
21717 64TH AVE CT E
SPANAWAY WA 98387 BUDGETARY
MICHELLE
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CITY OF YELM
RESIDENTIAL BUILDING PERMIT APPLICATION FORM
Project Address: /y/~sf~~ 5,~~..~4,~ 3T, ill ~c/ Parcel #: ~ 27 /~ ~ /O [ C L
Subdivision: Lot #: Zoning;
^ New Construction ~ Re-Model / Re-Roof /Addition n Home Occupation Sign
i ~ Plumbing C~ Mechanical U Mobile /Manufactured Home Placement Other
Project Description/Scope of W w ~~ mec~ ~ 5 t,i_•%~ R w, 1 t ~/eu s~ onl N~ w l~o~senla!`, •o,~
U^ _ ..
Project
Building Area (sq. ft) 1St Floor 2"d Floor Garage 1 C~+ r Deck~~
Basement Carport Patio
# Bedrooms 3 # 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.
ARCHITECT/ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTOR(~/t~ f s gas r /~a~,`„ ~ TELEPHONE Z~-3 _5 3S-'~3 S'
ADDRESSfG Y' C ~` ~ ~ - sllrryl~, ~-EMAIL
CITY l~,~eo>>u STATES^ZIP GI~Lt~c L 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 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.
~' ?-~~-off
' nt's Signature Date
Owner / ontractor /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 Auenue West (360) 4a8-3835
PO Box •179 (360) 458-3144 FAX
Yelrn, WA 98597 u~ww.ei..velnt.u~a.its
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General/Specialty Contractor
A business registered as a construction contractor with L~tl to perform construction work
within the scope of its specialty. A General or Specialty construction Contractor must
maintain a surety bond or assignment of account and carry general liability insurance.
Business and Licensing Information
Verify Workers' Comp Premium Status
Name CHET'S HOUSE MOVING >t
CONST
Phone No. (360) 832-4976
Address PO BOX 6
Suite/Apt.
City EATONVILLE
State WA
Zip 98328
County PIERCE
Business Type INDIVIDUAL
Parent
Company
Check for Dept. of Revenue Account
UBI No. ~ 601889403
Status ACTIVE
License No. CHETSHM034N5
License Type i CONSTRUCTION
J CONTRACTOR
Effective Date 8/25/1997
Expiration Date 9/4/2010
Suspend Date
Previous
License
Next License
Associated
License
Specialty 1 ~ CONCRETE
Specialty 2 J UNUSED
- Business Owner Information - Hide Alt
Name Role Effective Date Ex iration Date
TOMCZAK, CHESTER L OWNER 09/25/1990
Assignment of Savings Information i~
https://fortress.wa.gov/lni/bbip/Detail.aspx?License=CHETSHM034N5 9/4/2008
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Savings Assignment of
Savings Account Effective Release Assignment Impaired
Amount Received
Number Date Date Type Date Date
2 47102821693726 02/08/2002 Until
Released Bond
$2,000.00
2/8/2002
1 47122820224119 08/10/1997 Until
Released Bond
$4, 000.00
Insurance Information i
Insurance Company Policy Effective Expiration Cancel Impaired
Name
Number
Date
Date
Date
Date Amoy
10 UNDERWRITERS
AT LLOYDS pfk040095 09/03/2008 09/03/2009 $1,000,0
9 UNDERWRITERS PFK032723 06/28/2006 06/28/2007 $1
000
0
AT LLOYDS ,
,
WESTERN
8 HERITAGE INS SCP0569346 07/28/2005 07/28/2006 11 / 10/2005 $2,000,0
CO
WESTERN
7 HERITAGE INS SCP0569346 07/28/2005 07/28/2006 $1,000,0
CO
WESTERN
6 HERITAGE INS SCP366655 07/23/2004 07/23/2005 $1,000,0
CO
WESTERN
5 HERITAGE INS SCP366655 07/23/2003 07/23/2004 $1,000,0
CO
WESTERN
4 HERITAGE INS SCP366655 07/23/2002 07/23/2003 $1,000,0
CO
3 MONTICELLO MCL445552 07/23/1999 07/23/2002
INS CO
2 MONTICELLO MCL449199 07/23/1999 07/23/2000
INS CO
1 MONTICELLO MCL445552 07/23/1997 07/23/1999
INS CO
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https://fortress.wa.gov/lni/bbip/Detail.aspx?License=CHETSHM034N5 9/4/2008