20100212 Permit Pkg 01042011City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360)458-3144
Applicant:
Name: FOOT AND ANKLE SURGICAL ASSOC.
Address: 1610 BISHOP RD SW #7
TUMWATER WA 98512
Property Information:
site Address: 201 TAHOMA BLVD SE 208
Assessor Parcel No.: 21724130602 Subdivision:
Contractor Information
Permit No.: 20~ 002 2
Issue Date: 1/04/2011
(Work must be completed within 180 days)
Phone: 360-754-3338
Owner: YELM MEDICAL OFFICE
BLDG., LLC
EAGLE PLAZA Lot:
Name: FOOT AND ANKLE SURGICAL ASSOC. Phone:
Address: JESSICAL STUDEBAKER
1610 BISHOP RD SW #7
TUMWATER WA 98512
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: COMMERCIAL REMODEL
Description of Work: 1503 SQ. FT FOOT AND ANKLE TI
Sq. Ft. per floor: ~, _~ Heat Type (Electric, Gas, Other): COMBO-SEE NOTES
Second 1503
Third
Garage
Basement
Fees:
Item Contractor
MECHANICAL EVERGREEN REFRIGERATION
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 inconformity 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 c rrently
registered in th fate ashington. / I 1
Sionatur Date 1 7
Fees
$ 58.00
Sets of Prints:
final Inspection:
Date:
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CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: ,~c~ ~ ~a~v~~,c1 ~lY~;l $ ~ Parcel #:
Zoning; Current Use: Proposed
~ New Construction I i Re-Model / Re-Roof /Tenant Improvement
~ PlumbingMechanical ~_ Fire PreDvent/Suppress/Alarm I Other
Project Description/Scope of Work: ''/ U~1/ ,h/~k~S , _l~~y~n~~
Project Value: ~~~ ~~~U. C~~~
Building Area (sq. ft) Parking Garage 1ST Floor 2"d Floor 3~d Floor
Building Height
Are there any environmentally sensitive areas located on the parcel? _
completed environmental checklist must accompany permit application.
If yes, a
BUILDING OWNER/TENAN7 NAME: ' % ~ "' %
ADDRESS ~ '-' - ~~ L/ S~f~ %O ~ EMAIL
CITY ~, , ~, ;, ~r f;~.- STATE ice,= ZIP ~~~ss/~ TELEPHONE
ARCHiTECTfENG1NEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAhCONTRACTOR 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,CY~r;,~,•r~ ~f,t~M.~~i~~~TELEPHONE.~„~, 7i,~ /TY-~/
ADDRESS ~ ~ EMAIL~~~ ~,~,,,~C', ~P.~ ~CP~ NY/lC -~~;~>~
CITY ;< <> ri /,~=~ ~STATE~~ZIP 9~i~ S FAX -
CONTRACTOR'S LICENSE #FyEfl UfJ~ ~7syA,} EXP DATE! i~CITY LICENSE # ' ~~
Copy of City Mitigation documentation (TFC).
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.
~,. ~
Applicant's Signature Date
Owner /Contractor /Owner's Agent /Contractor's Agent 1 Tenant (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 Yedm Avenue Weat
PO Box 479
Yelm, WA 98597
~~~~~~
458-3835 ~ -
458-3144 FAX