20-100016CITY OF 4A
Federal Way
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter�a_)cityoffederalway.com
CITY 0* FEDEFAL WAY
COMMUNITY IDEVELOPMENri
PERMIT NUMBER _z� n — _ p' 0 0 Ly — C 0 TARGET DATE
SITE ADDRESS
SUITE/UNIT #
625 South 314th Street, Federal Way, WA 98003 d -70
n/a
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ 30,000
Single Family-1
unit 7,200 SF RS72
0 8 2 1 0 4- 9 0 3 5
— — — — —
TYPE OF PERMIT
® BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
Mirror Lake Elementary School Retaining Wall
Construct retaining wall as part of site improvements associated with elementary
PROJECT DESCRIPTION
Detailed description of work to
school replacement project.
be included on this permit only
NAME
PRIMARY PHONE
Mike Benzien, Federal Way Public Schools
253-945-5965
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
1211 South 332nd Street
mbenzien fw s.or
CITY
Federal Way
STATE I
WA
ZIP
98003
253-945-5959
NAME
Dan Eygabroad, FORMA Construction Company
PHONE
360-754-5788
MAILING ADDRESS
P.O. Box 11489
E-MAIL
dane@formacc.com
CONTRACTOR
CITY
STATE
ZIP
FAX
Olympia
WA
98508-1489
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
Dr. Tammy Campbell, Federal Way Public Schools
PRIMARY PHONE
253-945-2010
APPLICANT
MAILING ADDRESS
33380 8th Avenue South
E-MAIL
tcam bell(a,fw s.or
CITY I STATE I
Federal Way WA
ZIP
98003
FAX
253-945-2011
NAME
PRIMARY PHONE
PROJECT CONTACT
Casey Moore,'Federal Way Public Schools
253-945-5935
MAILING ADDRESS
1211 South 332nd Street
E-MAIL
cmooreg.fwps.org
(The individual to receive and
respond to all correspondence
CITY
Federal Way
STATE
WA
I ZIP
98003
FAX
253-945-5959
concerning this application)
PROJECT FINANCING
NAME
Federal Way Public Schools
0 OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
33380 8th Avenue South Federal Way,WA, 98003
PHONE
253-945-5930
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and flied against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
!r4%rmation supplied to t e city as a part of this application.
I
II,,
SIGNATURE: DATE Zv
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Bulletin #100 — January 29, 2016 Page 1 of 2 k:\Handouts\Pcrmit Application