BLD-05-0236
~/-"~,~
~
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Permit No
BLD-05-0236- YL
Issue Date. 08/01/2005
(Work must be started within 180 days)
Receipt No
37707
Applic:ant;
Name: Groeschel, Paul
Phone.
458-7646
Address. 514 Yelm Ave. West
City' Yelm
State. WA Zip 98597
Property Information:
Site Address. 514 Yelm Ave. West
Assessor Parcel No. 21724141502
Subdivision:
Lot:
Contractor Information.
Name: JKC Roofing
Contact:
Phone. 790-7770
Contractor License No: JKCROR*9610W
City' Olympia
Expires 03/16/0675
State. WA Zip 98512
Address. 11919 Shoreview
Business License:
Project Information:
Project: Theroputic Accociates
Description of Work: Re-roof
Sq. Ft. per floor (1st) 0
Heat Type (Electric, Gas, Other):
(2nd) 0
(3rd) 0
Garage 0
Basement 0
Fees:
Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc
-------------------------..- -------------
Building Permit - Other 111.25 000 000 0.0000 o 0000 $1,000
TOTAL FEES $111.25
Appli~nt's Aff~davit:
OFFICIAL USE ONLY
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 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 futher certify that I am currently
registered in the State of Washington.
Signature~ ~
Firm
Date
"I..or
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Permit Fees Schedule
PAID
Permit No BLD-05-0236-YL
AUG - P. )O(1~
CITY OF YELM
Applicant:
Address. 514 Yelm Ave. West
City' Yelm
3)107
Phone 458-7646
Name: Orasha, Paul
State. W A Zip 98597
Project Information.
Project: Theroputic Accociates
Description of Work. Re-roof
Site Address. 514 Yelm Ave. West
Assessor Parcel No. 21724141502
Fees.
Item
Acct Code
Item Fee Base Amt Unit Fee Unit Rate No Units Unit Desc
Building Permit - Other
032 001-322-10-00
111.25
000
000
o 0000
00000 $1 000
TOTAL FEES.
$111.25
PO Sox 479
Yslm WA 9859'7
360-458.8403
RECEIPT No 37707
)~ 'fr .k ;t. 0 N 8 }~ 1.) N D F E [1 E L E -\ T~ N
LC~I.!IJr-\'Gd t
:25 C'8ilT;~
RECEIVED fROM
DATE
REC. NO.
AMOUNT
REF NO
T I( \ 1= Cl Cl }.1 I N :J
,,-' - - ~,:".... r' ....-; r! 1:"1 - ;;.
eLl N T ( ) l'J "-_ C 1: 1: J...! 1..J 1.
11 9 1:; S d (] R E'V E I Vi D P S i'i
OLYMPIA WA 9J512
REPOOF
~}e/01/\-J5
'"]., -, f-' i
I ! ~J
111
=.t) rHEC'I,r
1664
2UDGETP.H -{
J P.~NINE
/
p :- , -L n c: rJ:: 3 (: { L r' , . " ''''
>- ........... - .. ..... r:J _", ,.., ,.!r1LL,. T :1'\ p. V lJ )'/ L:: '1
--;-, ~ - '1 t" . -J c'.,~ ,~ '.-i U.l, t -
F ER~:iIT JT\.C 0 J )f IL'~ .~"f ~., (!:- r-',,~ ~
RECEIVED
..**THI8fY rIVE DlLLAF~ & 00 ~ENT~
RECEIVED FROM
j'Y =: F ::OEING
].191~ SH:1PCVIEW DR SW
C L ~(1! P I A ~'l A j ::,5 1 :.
DATE
REG. NO
AMOUNT
REF NO
.J 3 / ,,) It 0 5 '3 7 7 0 3
?5 ()') _HECK
1665
BUD GET p\ R '{
Jl\NINE
I
./
,< P 1-; ~ 2 I 2J:: r\ I~ F ~. I (' ~i T I ( ) ;',1
c
c
c
CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: SlY Yelm /fuc.._
Parcel #"
d-I 7,), V I L) , ~o '--
,
..p~
('
4~ <<> t.-
o/ d <<'<)
~
Zoning;
Current Use
Proposed Use"
U New Construction ~ Re-Model/ Re-Roof / Tenant Improvement
U Plumbing U Mechanical U Fire PrevenVSuppress/Alarm
~~f
U Other
Project Description/Scope of Work:
'S:=-... 0
Project Value: " 00
1st Floor
3rd Floor_
2nd Floor
Building Area (sq. ft) Parking Garage
Q~
Building Height .Jl
Are there any environmentally sensitive areas located on the parcel? --1..0.....-
completed environmental checklist must accompany permit application
If yes, a
BUILDING OWNERfTENANT NAME.
ADDRESS S I Lf rt h.. ~~
CITY STATE ZIP
ARCHITECTIENGINEER
ADDRESS
I CITY STATE
GENERAL CONTRACTO
I
ADDRE~S
CITY Q
CONTRAC
ZIP
LICENSE #
EMAIL
TELEPHONI:::
TELEPHONE 710 - 770
EMAIL
0i FAX
EXP DATE~CITY LICENSE #
TELEPHONE
EMAIL
FAX
EXP DATE CITY LICENSE #
PLUMBING CONTRACTOR
ADDRESS
CITY STATE
CONTRACTOR'S LICENSE #
ZIP
MECHANICAL CONTRACTOR
ADDRESS
CITY STATE
CONTRACTOR'S LICENSE #
TELEPHONE
EMAIL
FAX
EXP DATE CITY LICENSE #
ZIP
Copy of City Mitigation documentation (TFC).
I hereby certtfy 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 ofYelm.
~_.~. ~
.--- ~' .c-:
Applicant's Signature
Owner I Contractor I Owner's Agent I COl1tractor's Agent I Tenant
p-( - oS-
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
105 Yelm Avenue West
PO Box 479
Yelm. WA 98597
(360) 458-3835
(360) 458-3144 FAX
www.ci.yelm.wa.UB
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General/Specialty Contractor
A business registered as a construction contractor with Lal to perform construction work within the scope
of its specialty A General or Specialty construction Contractor must maintain a surety bond or assignment
of account and carry general liability insurance
License Information
License JKCROR-961 DW
Licensee Name J K C ROOFING
Licensee Type CONSTRUCTION CONTRACTOR
UBI 601331960 Verify Workers Comp Premium
Status
j Ind. Ins. Account
Id
Business Type LIMITED LIABILITY COMPANY
Address 1 11919 SHOREVIEW DR
Address 2
City OLYMPIA
County THURSTON
,
State WA
Zip 98512
Phone 3607907770
Status ACTIVE
.. Specialty 1 G UTTERS/ DOWNSPOUTS
Specialty 2 ROOFING
Effective Date 3/16/2004
Expiration Date 3/16/2006
Suspend Date
. Separation Date
Parent Company
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Business Owner Information
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https.//fortress. wa.gov/lmlbbIp/Detai1.aspx?LIcense=JKCROR *961 DW
8/1/2005
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Name
Role
Effective
Date
Expiration
Date
COFFELT,
CLINT
PARTNER/MEMBER 03/16/2004
Bond Information
Bond Bond
Company Account Effective Expiration Cancel Impaired Bond Received
Bond Name Number Date Date Date Date Amount Date
ACCREDITED
SURETY 8: Until
#1 CAS CO 10014069 03/10/2004 Cancelled $6,000 00 03/16/2004
Savings Information
No Matching Information
Insurance Information
Company Policy Effective Expiration Cancel Impaired Received
Insurance Name Number Date Date Date Date Amount Date
PRIME INS
SYNDICATE
#2 INC PRC2518RCO 03/14/2005 03/14/2006 $250,000 00 04/11/2005
ATLANTIC
CAS INS
#1 CO L088002418 03/10/2004 03/10/2005 $300,000 00 03/16/2004
Summons / Complaints Information
Tax
Summons / Cause Warrant
Complaint Number Id Plaintiff County
WAST
DEPT OF
REVENUE KING
Dismissal Complaint Complaint Judgement Judgement Pa
Date Date Amount Date Amount I
#1
052240423
07/27/2005 $3,075 95
$000
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