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CITY OF,FEDERAL WAY
BUILDING PERMIT APPLICATION
—Please Print—
BOX 1 TENANT NAME:
OWNER C zr Lev j< SITE LOCATION 28i cxl 28 Av€ s
OWNER'S ADDRESS 2? L) L - coir7rnoo0 07 ciL.v CITY eL4 tt-I-e PHONE.1B'/- 4/c90
DESCRIBE JOB
THE PROPERTY IS OWNED BY: SINGLE/MARRIED PARTNERSHIP CORPORATION
BOX 2 CONTRACTOR'S NAME in] r unc�,�rt,1 +p/L,,y► 17,k CONTRACTOR'S REG. #Tivt-cr, 4 .25'E/6L
Card MUST be pr to
CONTRACTOR'S ADDRESS 36f,5-6' 1v /1 tile Cy l'P 4 CITY au burn.) CuH PHONE .?
EXPIRATION DATE q/v/gf
— OR—
I HAVE READ CHAPTER 18.27.010 RELATING TO DEFINITIONS OF GENERAL CONTRACTORS AND SPECIALTY CONTRACTORS AND
CHAPTER 18.27.110 WHICH PROHIBITS ISSUING PERMITS WITHOUT PROOF OF REGISTRATION.
BOX 3 CONTACT PERSON PHONE
BOX 4 SEWER DISTRICT WATER DISTRICT
BOX 5 ESTIMATED PROJECT COST EXISTING BUILDING VALUATION
BOX 6 PROPERTY TAX ACCOUNT NUMBER % 3/2 '/G7 4010
LEGAL DESCRIPTION in f" 2 Elery 1/4.,n ri 010 wive,V`
(If necessary, please submit a separate page with the legal description.)
K.C. Plat Recording#
BOX 7 BUILDING SQUARE FOOTAGE: (Existing/Proposed) 1ST FLOOR / 2ND FLOOR /
3RD FLOOR / BASEMENT / _ DECK / GARAGE /
BOX 8 (x) SINGLE FAMILY (X) NEW CONSTRUCTION
( ) MULTIFAMILY(NO. OF UNITS = ) ( ) EXISTING STRUCTURE
( ) COMMERCIAL/INDUSTRIAL TOTAL AREA OF PROPERTY SO FT
BOX 9 PLUMBING FIXTURES(including rough-ins) MECHANICAL APPLIANCES— BASIC FEE$
NO. 3 WATERCLOSETS GAS PIPING, FEET $
_,A—BATHTUBS NO. FURNACE, ELEC. GAS $
1 SHOWERS GAS HOT WATER HEATER $
z/ LAVATORIES CONVERSION BURNER $
1 SINKS BOILER, SIZE BTU $
1 DISHWASHERS AIR HANDLING UNITS $
r'r vey R#6 HOT WATER HEATER HEAT PUMPS, SIZE $
1 LAUNDRY WASHER OUTLET UNIT HEATERS $
URINALS AIR COOLING UNITS, SIZE $
DRINKING FOUNTAINS COMMERCIAL HOOD $
SUMPS, SPRINKLER VACUUM BREAKERS OTHER $
DRAINS $
OTHER $
iq TOTAL FIXTURES $
TOTAL MECHANICAL FEE $
I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE ABOVE PREMISES TO PERFORM THE WORK FOR WHICH PERMIT APPLICATION IS
MADE.I FURTHER AGREE TO SAVE HARMLESS THE CITY OF FEDERAL WAY AS TO ANY CLAIM(INCLUDING COSTS,EXPENSES,AND ATTORNEYS'
FEES INCURRED IN INVESTIGATION AND DEFENSE OF SUCH CLAIM),WHICH MAY BE MADE BY ANY PERSON, INCLUDING THE UNDERSIGNED,
AND FILED AGAINST THE CITY OF FEDERAL WAY,BUT ONLY WHERE SUCH CLAIM ARISES OUT OF THE RELIANCE OF THE CITY, INCLUDING ITS
OFFICERS AND EMPLOYEES, UPON THE ACCURACY OF THE INFORMATION SUPPLIED TO THE CITY AS A PART OF THIS APPLICATION.
OWNER/AGENT: 1-t_t,e /1�, DATE: '—/7— f�
ANP-008 3/90
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