ApplicationCITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: 201 Tahoma Blvd SE, SUlte 208 Parcel #: 21724130600, 27724130500, 21724130602
Zoning; C-1 Current Use: ~B' -Business proposed Use: 'B' -Business
[! New Construction X Re-Model / Re-Roof /Tenant Improvement
Plumbing Mechanical Fire Prevent/Suppress/Alarm I Other
Project Description/Scope of Work: Interior build-out 1,503 SF clinic on the 2nd Floor of the MOB
Project Value: $150,300
Building Area (sq. ft) Parking Garage NA 1S1 Floor 17.456 2ntl Floor 15.9003rtl Floor NA
Building Height 35'-0"
Are there any environmentally sensitive areas located on the parcel? no If yes, a
completed environmental checklist must accompany permit application.
BUILDING OWNER/TENANT NAME: Foot and Ankle Surgical Associates (Jessica Studebaker)-
ADDRESS 1610 Bishop Road SW Bliildinq #7 EMAIL hessdpm@comcast.net
CITY Tumwater STATE ~(~ZIP 98512 TELEPHONE~360) 754-3338
ARCHITECT/ENGINEER TGB Architects LICENSE # 3626 (L. Kent Gregory)
ADDRESS 21911 76th Ave W Suite 210 EMAIL gdais@tgbarchitects.com
CITY Edmonds STATE WA ZIP 98026 TELEPHONE (4251778-1530
GENERAL CONTRACTOR TBD TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PLUMBING CONTRACTOR Design/Build -TBD TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL C~3NTRF~CTOR Design/Build -TBD TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE 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.
Owner /Contractor / wner's Agen /Contractor's Agent I Tenant
~v Z.sJ zp~Q
Date
(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
705 1'ednx AoenGe [T'esl
PO73oz 479
1'elm, 1TA 98597
(3G0) 458-3835
(3G0) 458-3194 FAX
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