05-106212arror .:. RECEIVED
ED
Federal Way PERMIT
coMEDERAL EVELWA 980 3-9718 ESp E C o 6 ' P LI C AT I O N
333258TH AVENUE SOUTH • PO BOX 971
FEDERAL WAY, WA 98063 -9718
253835.2607•FAX253835 -2 .�Y OF FEDERAL WAy
tumro eittto/(ederdway rnm -
BUILDIN4 DEPT,
The foiloudng is required information - an incomplete application will not be
SITE ADDRESS --�—i V f p( Y r k'
ASSESSOR'S TAX /PARCEL #F S
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
0s -10 6 -2 1
SF MF CO ME EL PL DE El
Please print legibly (in ink) or
SUITE /UNIT #
LOT SIZE (s,)
(Attach separate pope (ar lengthy lepat deurotionj
'• •- •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL 11 ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed / �n
d des io n of work included on this permit onlul riw,
PROJECT NAME (Name of Business or Owner Last Name) Ce l �
e� 19 yj S[j►, yt�, I I l -
PEOPLE •- •
PROPERTY
OWNER
CONTRACTOR CITY
NAME r ` �RIMARY; HONE _
a ��/ ki ve-A � MAILING ADDRESS CITY, STATE, ZII`P_ ,1
CO NAME
IC , 1
APPLICANT NAME
Lko'Atl
OFJICE PHONE
51 -1v
I ING ADDRESS
A
CE �
CITY, STATE, ZIP
t Q
C7C
C ;1.1, PHONE
-/
Qt C' u
(;4 ) y
OF FEDERAL WAY B SINESS LICENSE NUMBER
EXPIRATION DATE
FA��X//NUMBER
— — B
L / l
(�
(W ?7/
CONTRACTOR'S REGISTRATION NUMBER (eopy of cud 4kuired
with each application)
EXPIRATION DATE
APPLICANT COMPANY
W 1 ( ) _
MAILING AD CITY, ,ZIP - CELL PHONE
RELATIONSHIP TO PRO FAX NUMBER
o Architect ❑ nt O O ther (Describe) _
Corp
F— AREA DESCRIPTION ESO. FT.(} PROPOSED TOTAL
SO. FT. I SO. FT. So_ rr_
FIRST
SECOND
THIRD
FOURTH
(DESCRIBE)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS �osrac
"NEW HOMES ONLY'' NUMBER OF BEDROOMS
TOTAL
PRICE
each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
BBQS
FANS
HOODS(com miaq
WOODSTOVES
BOILERS
FIREPLACE INSERTS
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
GAS WATER HEATERS
DUCTS
GAS PIPE OUTLETS
PLUMBING
BATHTUBS (or Tub /showercombo)
SHOWERS
WATER CLOSETS (Po11eq
M[SC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPE OUTLETS
SUMPS
RAINWATER SYST
WASHING MACHINES
URINALS
HOSE BIBBS
IAVS (eathroomsinka)
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I cer ft under penalty of perjury that the igormation furnished by me is true and correct to the best of my knowledge, and further, that I
am authorized by the owner oft I abSve premises to perform th work for which the permit application Is made. I further agree to hold
harmless the City of Federal Way t claim (including costs, expenses, and attorneys' fees Incurred in the investigation and defense of
such claim), which may be made by a Including the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the reliance of the city, inclhdNtg its ofjbcers and employees, upon the accuracy of the igformation supplied to the city as a part of
this application. r s
NAME /TITLE \ �G (/(/l , DATE Id` 6,05-
(Signature) gyp! a (Title)
RELATIONSHIP TO OJECT ❑ Owner Agent ❑ L'dr�act�r W ❑ Ar�ckr tect ❑ Other
Bulletin # I00 — January 7, 2005 Page 2 of 4 MandoutsTermit Application