201 Tahoma Blvd SE ��-�-,--� � 1 -� � - ,z
ENC JH 145998 CITY OF YELM � �
CHK103112 $3 n --- _-_—
� � DEC 0 1 2012
�,.�� T�� � C�TY OF YELM aF �A SEONLY __
�, �►� � 105 Yelm Ave. W. FEE
�Q � Yelm, WA 98597 Comm Dev.Dept.
a �� (360} 458-8437 OFFICE eldg Dept.
6� (360} 458-�348 FAX
Insp.Date
� www.ci.yelm.wa.us
lfo.No. ,
�`� APPUCATION FOR C�
YELM BUSINESS LICENSE
WASH1NC70N ���
Upon receipt of the license application and$35.00 payment,the City of Yelm will conduct an inspection
the premises for building and fire code conformance. Upon appro�al from the Yefm Building Department
of said premises, the City Cleric's Office will process the application and mai!license to appficant at
address listed below.
Application is hereby mad�e for a Business License for the City of Yelm
� NEW BUSINESS ❑ NAME CHANGElMAILING ADDRESS CHANGE ONLY
DATE U Z
BUSlNESS NAME ! - � � - � D � JC
NATURE OF BUSINESS�}�f�/(�j�(' / ��� �� �m�6iN6 ��LJ�
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BUSlNESS Lt�CAT10fV ADQRESS�(� j ��}/��j�"J� L � s�
MAILING ADDRESS �'m ��
ANTICIPQTEp pPENING DATE ��ti" �� B��GH
DAYS�HOURS OF OPE TION 9 /n — �I S d.- —
OWNER{S) �� �
Bi rth date
Add�ess
C�h+ State Zip
TELEPHOIVE — — '
(Business) (Home/Emergency)
CONTRACTOR'S REGISTRATiON NO.
(If applicable)
THURSTON CO. HEALTH APPROVA�NO.
STA7E OF WASHINGTON MASTER BUSINESS LfCENSE NO.(U61} 3l��?- 9��
Signature JX'� Qate 111�,.��2
I
Page 1 of 1
�'��s�iulgton St�te I�epai�netl� ofRevenue
S#�te Bu�uiQSS Rec�ar'iI5 D�t��AS� D�'t�ll
TAX REGISTRATIQN M0: 313007977 ACCUUNT OPEMED: O1J01/1980
UBI: 313007977 ACCOUNT CLOSED: OPEN
ENTITY NAME: PROYIDENCE HEALTH 8r SERYICES WA
BUSINE�S NAME: PROYIDENCE WASHINGTON SERYICE CENTER
MAILING ADDRE55: BU5INE55 LOCATION:
ATTN TAX DEPT
2001 LIND AYE 51�J 4831 35TH AVE SW
RENTON,WA 98Q57-33Q3 SEATTLE,WA 98126-2709
ENTITY TYPE: NON PROFIT CORP RESELLER PERMIT MU: A16 8609 13
PERMIT EFFECTIYE: O1/O1/2010
MAICS CQDE: 622110 PERMIT EXPIRES: 1�/31 j2013
NAICS DEFIMITIQN: GENERAL MEDICAL AND
SURGICAL H05PITALS(PT)
F�R N�N-��MMER�IAL USEOhlLY
12j0�f2012 10:51 AM
http://dor.wa.gov/images/BRDImage.aspx?tra=CVgDQI8ZGwd1 iqavSBs2xA07M4LQFle... 12/3/2012