07-101872CITY OF � `
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i ii
Federal Way P E R M T
COMMUNINDEVELOPMENTSERVICES MF CO ME EL PL DE EN FP
33325' AVENUE SOUTH . BOX APPLICATION
FEDERAL WAY, WA 98063 63 -9718 TD
.253.83S -2607• FAX 253. 835.2609 ^
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The following is requirbd informant -0hincomplete application will not be accepted. Please print legibly (in ink) or type.
PROPERTf INFORMATION
SITE ADDRESS a SUITE /UNIT #
ASSESSOR'S TAX /PARCEL # - .- *)<I0 LOT SIZE (s])
r — —
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page fm lengthy legal desotptimQ
PROJECT • •
TYPE OF PERMIT ❑ BUILDING El 'PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING LIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE •• •
PROPERTY
NAME PRIMARY PHONE
OWNER
CONTRACTOR
COPY of cvd required
ielth each appllntlon
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
COM
H
ANY NAME
.
VT
OFFICE PHONE
MAILING ADDRESS
APPLICANT NAME
CITY, STATE, ZIP
E -MAIL ADDRESS
COM
H
ANY NAME
.
VT
OFFICE PHONE
MAILINq ADMRES.
APPLICANT NAME
1
OFFICE jNON E
-
MAIL O ADDRESS
_
CI ATT
CELE�LL�� PP)ONE
CITY F FEDERAL WAY BUSINESS LICENS
NUMBER E PI RATION DA
FAX NU BER
CONTRACTORS REGISTRqION NUMBER
EXPIRATION DtA}TE�1
E -MAIL ADDRESS
COMPANY NAME
_.H la 4 10.4k
APPLICANT NAME
OFFICE PHONE
MAILINq ADMRES.
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other
_
NAME - � �� PRIMARY. � HO� NE . _ � E-MAIL ADDRES3
- NAME
Per RCW 19,27.09S.'
9.27 095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $ _-DW(9L )
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN b HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or TuWsho rCombo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
(A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
FANS GAS WATER HEATERS MISC (Describe)
FIREPLACE INSERTS HOODS (commerriaq
FURNACES RANGES
GAS LOG SETS REFRIG. SYSTEMS
LAVS 19athroom Smka)
URINALS MISC (Describe)
RAINWATER SYST
VACUUM BREAKERS
SHOWERS
WATER CLOSETS rroseq
SINKS
WASHING MACHINES
SUMPS
I certify under.penalty of perjury !hat 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 the permit application is made. 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 fired 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 accuracAr of the 1r;formation supplied to the city as a part of
this application.
NAME /TITLE DATE —rte
lgnature) (Title)
RELATIONSHIP PROJECT Owner Agent ❑ Co tractor o Architect ❑Other
o NEW o ADDITION o ALTERATION o REPAIR ❑ TENANT IMPROVEMENT.
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? o YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP /SEPA /SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin #100— January 1; 2007 Page 2 of k4landoutAPermit Application .