06-103854J
Fedem[ Way RIEC IVED PERMIT
COMMUNIIYDEVELOPMENT SERVICES
333258w AVENUE SOWN • PO BOX 9718
FEDERAL WAY, AX2S3 3 26'o9AU o ZOa�PPLI CATI O N
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The following ii RF,&# _ _ Wn incomplete application will not be ac
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cited. Please print legibly fin inkJ or tune.
SITE ADDRESS `a PLkii
ASSESSOR'S TAX /PARCEL # �ff— C) 0
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
SUITE /UNIT 1 —I
LOT SIZE (s j)
(Anach separate page %ar lengthy kgd dmca0d.Q
PROJECT • •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING GFIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
NAME PRIMARY PHONE
MAILING ADDRESSS CITY, STATE, ZIP
COMPANY NAME
PfPLICANT NAME
APPLICANT NAME
OFFICE PHONE
�PHONE
MAILING ADD S�` ^�
STATE,
MAJOR DR
E
_
. ,
C IT, STATE, ZIP
n
CELL PHONE
1, >,
CITY OF FEDERAL AY BUSINESS
Q
LICENSE NUMBER I T O DATE --
L -1 - B L,
'FAX NUMBER
(0S "jG'a a -
CONTRACTORS REGISTRATION NUMBER (copy of card required with each applicatioaj
EXPIRATION DATE
COMPANY NAM
PfPLICANT NAME
OFFICE
�PHONE
MAILING ADD S�` ^�
STATE,
CELL PHONE
RELATIONSHIP SH[P TO PRWECI
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent 0 Other (Describe i�}11Yf .( 1(Y
) q -
Q
AREA DESCRIPTION EXISTING PROPOSED TOTAL
S . FT. S . FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS wasrma rsoros= Tone nrR :Rp cal 'bi'' iYr "°
"NEWHOMES ONLY"* NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
NECRAMCAL -
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOG REFRIG. SYSTEMS
BBQS FANS S (commereieQ WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC (Describe)
COMPRESSORS - I'(JRNACES a WATER HEATERS
DUCTS GAS PIPE O
BATHTUBS (or Tub /Shower combo) SHOWERS WATER CLOSETS
gotleq M[SC (Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE O S SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS (e —ooswo VACUUM BREAKERS ELECTRIC WATER HEATERS
I cer ft under penalty of perjury that the tnformation 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 ctaiml, 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.
NAME/TITLE DATE
(Signature( (Title(
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
•
Bulletin # 100 —January 7, 2005 Page 2 of 4 k\HandoutslPermit Application