07-104358CITY OF 07
Federal Nay RECEIVES ���,`� - --��—� 3
PERMIT SF MF (CQ) ME EL PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES `�----�J
33325 D AVENUE SOUTH • 63 971 9718 p p L I C AT I O N
FEDERAL WAY, X 980 35-26 8 A 0 0 0 6 20
' 253-835-2ti07• FAX 253-835-2609
mtb tu. !%du+t h wt u^tvm
CITY OF DERA YV�,�'
The following is req*jCq f! - an incomplete application will not be accepted. Please print legibly (in ink) or type.
__3
SITE ADDRESS 36 1105 SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # \ �. y��1,vs7 i� C
LOT SIZE (s�
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for lengthy legal descriptfon)
A
PROJECT INFORMATION
TYPE OF PERMIT UILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
P� T
ROJECT NAME (Name of Business or Owner Last Name) �-•'*'� �� ����7.5��`=f� � 1
PEOPLE•• •
PROPERTY
OWNER
CONTRACTOR
COPY of card regalred
with each application
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NA PRIMARY PHONE
MAILING
LADDRESS
'^\'�buADDRESS
ZIP
Cl ^�6111-
10%� �Q.I�7G��l�zlc.�•�1
COMPANY NAME
`3w. C>v _
APPLICANT NAME
,.��� 4�
OFFICE PHONE
(zc� )ASV
- 05� L
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
\
Ldlk
CONTRACTOR'S REGISTRATION
ISTRRATION NUMBER
EXPIRATION D�+ATTEE
E-MAIL ADDRESS
,
COMPANY NAME
P SOANT NAME
OFFICE PHONE
MAILING ADDRESS
e.�.� v59\�,.b��
ITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant Agent ❑ Other
(Z-5,b) (DOA
NAME� ' Q PRIMARY PHONE E-MAIL ADDRESS
NAME
P CW 19.27.095.
rider information is required ifproject value exceeds $5,000
MAILING ADDRESS
ITY, STATE, ZIP
PHONE
( ) -
EXISTING ASSESSED/APPRAISED VALUE $
SPRINKLERED BUILDING? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVE-
USE
_.VALUE OF PROPOSED WORK $_
SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
15 RIGHLINLN ❑ TACOMA ❑ PRIVATE (WELL(
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
:LIM
Indicate number of each type of fixture to be installed or relocated as part'of this project: not include existing fixtures to remain.
MECIfAN7C4L
Value of Mechanical Work $ (A COPY OF BID OR ESTIMATE MUS INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS FANS GAS WATER. HEATERS MISC (Describe)
BOILERS FIREPLACE I NS_ -SRf HOODS (com crclaq
COMPRESSORS 'l21ACRAJgGES
DUCTS �t SETS REFRIG. SYSTEMS
PLUMBING
BATHTUBS I rT 1.j: r:vwrcC6mhay LAV.S (Bathroom sucks) URINALS MISC (Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS (r.0 q
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
-___- HOSE BIBBS - SUMPS 1
I certify under penalty of perjury that the information furnished by me is true and correct to the beat nf•my knowledge, and further, that I
am authorized by the owner of .the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way as to any claim lincluding costs, expenses, and attorneys' foes incurred in the investigation and defense of
such claim], which maybe made by any person, including the undersigned, and filed against the C(ty 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.
NAME/TITLE t•
IS gaa
RELATIONSHIP TO PROJECT
l
�s DATE
❑ Owner bCAgent ❑ Contractor ❑ Architect ❑
❑ NEW o ADDITION
o ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY?
❑ YES ❑ NO
BASIC PLAN?
❑ YES
n NO
ZONING DESIGNATION
CHANGE OF USE?
o YES
o NO
NEW ADDRESS REQUIRED?
o YES o NO
UP/SEPA/SU?
o YES
❑ NO
PLATTED LOT?
o YES ❑ NO
DEMO PERMIT REQUIRED?
o YES
o NO
Bulletin #100—April 2, 2007 Page 2 of MHandoutsTermit Application