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Federal way .uN 15 20N PERMIT Vk
COMMUNITY DEVELOPMENT SERVICES . w r AV SF MF CO ME EL PL DE El
33325 D AVENUE , WA 9 • PO BOX 9t7 ,ry CCGDSC r �j �') LI CATION - J
FEDERAL WAY, WA 98063 -97e1� WF FEDER r r /
253 - 835 -2607• FAX 253 -835 -2609
www.cttgolfederalwati.cont
The following is required information - an incomplete application will not be accepted. Please print legibly (in ink) or type.
PROPERTY INFORMATION
SITE ADDRESS I0 /0 S* 3-%r= 5—j ' SUITE /UNIT # 10 2-
ASSESSOR'S TAX /PARCEL # 9 z W J 0 /- U V 1 0 LOT SIZE (sf%
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for lengthy legal description)
PROJECT • •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑MECHANICAL
11 DEMOLITION ❑ ELECTRICAL ❑ ENGINEERIN PREVENTION SYSTEM
DESCRIPTION (Provide detailed description of work included on this permit onlu)
U61ON6- ,qf?C- AI ,4RM 1111 Pro J6MdW7-5
AM 14a-AT-5, 4. -et --V- 11 Avd : o d- VeSuAL- 13L;-y1 coT3
PROJECT NAME (Name of Business or Owner Last Name) UH /,
PROPERTY
OWNER
CONTRACTOR
Ef
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
PEOPLE INFORMATION
to
NAME
PRIMARY PHONE
MAILING ADDRESS
CITY, STATE, ZIP
Wi
E -MAIL ADDRESS
❑ LAKEHAVEN
COMPANY NAME
-R..tl %A4 S4SC.UR -tT
APPLICANT NAME
6A06- 51Z-0 NS-, .
OFFICE PHONE
(2S3) 638 - 1792
MP41NG AD S
0 ?(-i i
CITY, STATE, ZIP
eg A. 9 y
CELL PHONE
c ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
(2S3) �3 -U396
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE
Ls� /�SL�OZZj� 03 %Zo o
E -MAIL ADDRESS
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other
FAX NUMBER
NAME
ANL
PRIMARY PHONE
63 -17rZ
E -MAIL ADDRESS
NAME
Per RCW 19.27.095:
Lender irtformation is required (f project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED /APPRAISED VALUE
SPRINKLERED BUILDING?
YES ❑ NO
WATER SERVICE PROVIDER
❑ LAKEHAVEN
SEWER SERVICE PROVIDER
❑ LAKEHAVEN
PROPOSED USE C�
VALUE OF PROPOSED WORK $
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
t �
A J ,
AREA DESCRIPTION
EXISTING
FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
FIRST
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
SECOND
HOODS [coo—w)
COMPRESSORS
FURNACES
THIRD
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
ADDITIONAL FLOORS (DESCRIBE)
DECK (❑ COVERED OR ❑ UNCOVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
effismvc
PRO—ED
mrnc
rarv.FnsMOS11
rorncrxoros ®sr
7 TALSr
* *NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing futures to remain.
MECHANICAL
URINALS MISC (Describe)
RAINWATER SYST
Value of Mechanical Work $
(A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
BBQS
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
FIREPLACE INSERTS
HOODS [coo—w)
COMPRESSORS
FURNACES
RANGES
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
BATHTUBS (or TUB /Shower Combo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
LAVS (Bathroom Smks)
URINALS MISC (Describe)
RAINWATER SYST
VACUUM BREAKERS
SHOWERS
WATER CLOSETS rrmla)
SINKS
WASHING MACHINES
SUMPS
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 in ormation 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 laim), which may be made by any person, including the undersigned, and filed against the city, but only
where such clat arise out % th� reliance of the city, including its officers and employees, upon the accuracy of the information supplied to
the city as a p th' pplicatt .
SIGNATURE:
❑ NEW ❑ ADDITION
BUILDING SHELL ONLY?
ZONING DESIGNATION
NEW ADDRESS REQUIRED?
PLATTED LOT?
b'Z-,5- 2c-/
Bulletin #100 —January 1, 2009 Page 2 of 4 k\Handouts\Permit Application