20100211 Permit Pkg 01042011City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Applicant:
Name: PROVIDENCE HEALTH SYSTEM
Address: 413 LILLY RD NE
OLYMPIA WA 98506-5166
Property Information:
Site Address: 201 TAHOMA BLVD SE
Assessor Parcel No.: 21724130602 Subdivision:
Contractor Information
Name: PROVIDENCE HEALTH SYSTEM
Address: ROBERT WATILO
413 LILLY RD NE
OLYMPIA WA 98506-5166
Contractor License No.:
Project Information:
Project: COMMERCIAL REMODEL
Permit No.: 20100211
Issue Date: 1!04/2011
(Work must be completed within 180 days)
Phone: 360-493-7194
Owner: YELM MEDICAL OFFICE
BLDG, LLC
EAGLE PLAZA Lot:
Description of Work: 2215 SF TI FOR PROVIDENCE HEALTH SYSTEM, 2ND FLOOR
Sq. Ft. per floor: Heat Type (Electric, Gas, Other): COMBO-SEE NOTES
Fees:
First
Second 2215
Third
Garage
Basement
Item Contractor Fees
BUILDING PROVIDENCE HEALTH SYSTEM $ 2,766.96
MECHANICAL EVERGREEN REFRIGERATION $ 77.00
FIRE SPRINK ACE FIRE SYSTEMS $ 160.46
TOTAL FEES: $ 3,004.42
Expires: 0/00/0000
OFFICIAL USE ONLY
Sets of Prints:
final Inspection:
Date:
By: _
Phone:
Applicant's Affidavit:
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
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CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: ~ ! (,r~n/~MC1 P/b~ S r Parcel #:
Zoning; Current Use: Proposed
^ New Construction ^ Re-Model / Re-Roof 1 Tenant Improvement
^ Plumbing Mechanical ^ Fire Prevent/Suppress/Alarm ^ Other
Project Descript' n/Scope of Work: ~, ~~ ,~~1'X~c . 1 Jli~7~(~r~c~ r
Project Value:_ / ~/,, ~(C~ ~ D~
Building Area (sq. ft) Parking Garage 1ST Floor 2"d Floor 3`~ Floor
Building Height
Are there any environmentally sensitive areas located on the parcel? _
completed environmental checklist must accompany permit application.
if yes, a
GENERALCQNTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
I?'LUMBING Ct)NTRACTEOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL-CONTRACTOR~ytr~~rr„ i~~fi~.er-a~io~TELEPHONE,~,~1 7/~~5 /7~'-i/
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CONTRACTOR'S LICENSE #~1/Ff1 U~~ ~i5 l f~ }~ EXP DATEj-o i,~CITY LICENSE #in -cX>io7`/. o
Copy of Clty Mitigation documentation (TFC).
I hereby certify that the above Information is conect 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.
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Applicant's Signatur. Date
Owner /Contractor !Owner's Agent /Contractor's Agent /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 Yelm Avenue West
PO Box 479
Yelm, WA 98597
<,;4:~
(360) 3835
(360) 458-3144 FAX
www.ci.~il1n.wa.us _____________