ApplicationCITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: 201 Tahoma Blvd SE, suite 204 Parcel #: 21724130600, 21724130500, 21724130602
Zoning; C-1 Current Use: 'B' -Business Proposed Use: 'B' -Business
f;; New Construction X Re-Model / Re-Roof /Tenant Improvement
Plumbing Mechanical Fire Prevent/Suppress/Alarm Other
Project Description/Scope of Work: Interior build-out 2,215 SF clinic on the 2nd Floor of the MOB
Project Value: $221,500
Building Area (sq. ft) Parking Garage NA 151 Floor 17.456 2ntl Floor 15.900 3rtl 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: Providence Health System {Rob Watilo)
ADDRESS 413 Lily Road NE (MS 02H03)_ EMAIL robert.watilo(a)orovidence.org
CITY Olympia STATE~/V~ZIP 98506 TELEPHONE~360) 493-7194
ARCHITECTIENGINEER 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 I42F) 778-1530
GENERAL OONTRACTOR Aldrich & Associates TELEPHONE (425) 483-1313 (Brendon Warme)
ADDRESS 810 240th Street SE EMAIL bwarme analdrich-assoc com
CITY Bothell STATE WA ZIP 98021 FAX (425) 486-1018
CONTRACTOR'S LICENSE # 22301 EXP DATE2igi11CITY LICENSE # 09-000050.0
PLUMBING CONTRACTOR Design/Build -TBD TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR 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 I Contractor's Agent /Tenant
/D yp ~
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 }'etm Auenr~-e West (360) 458-3835
PO Bor 479 (360) 458-3744 FA1
Ye(-m, I~i'A 98597 uunur.ci.yelrn..wa.us