20150117 FA App.CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: /06ZO dreeJ�' Parcel #: (4303LI00400, 5Di I 5C)2-
Zoning;
Current Use: Proposed Use:
,<'New Construction ❑ Re -Model / Re -Roof / Tenant Improvement
❑ Plumbing ❑ Mechanical V Fire Prevent/Suppress /Alarm ❑ Other
Project Description /Scope, of Work: t ( Re ALA se M S -q-�r& AA PFD J
Project Value: Coo a UO
Building Area (sq. ft) Parking Garage 1" Floor 2nd Floor 3'd Floor
Building Height
Are there any environmentally sensitive areas located on the parcel? If yes, a
completed environmental checklist must accompany permit application.
BUILDING OWNER/TENANT NAME6r•e-ek KA. 1/l x_,eci Ut .{a P14- aL
ADDRESS �?40 S+o, -Akuvr UJ2�i 5 - EMAIL
CITYTcZCoMoL STATE w A- ZIP C("QZ_ TELEPHONE
ARCHITECT /ENGINEER LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTOR cc TELEPHONE
ADDRESS -Z40 5kc cUQW( (_C122 EMAIL
CITY!ck_i_i VKo,, STATE LVP ZIP C 400 FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
PLUMBING CONTRACTOR TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
MECHANICAL CONTRACTOR // ?><U^- Ce prConbg �STELEPHONE 253-fK3 -L qQC>
ADDR SSr1d. 30 EMAIL Jg_f��Ivy I-Cf o C0 scowl
CITY C" 0,e STATE jL)4 ZIP g9Z)_)S3 FAX
CONT TOR'S LI ENSE # RCSIoI G EXP DATE CITY LICENSE # loon
Copy of City Mitigation documentation (TFC). 10141
1 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.
s
Applicant's Signature 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 Ave W
Yelm, WA 98597
T 1 R 2015
(360) 458 -3835
(360) 458 -3144 FAX
wwW.ci.yelm.wa.us
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