06-103688r QC `'
= ctry or • Ec E i Y
Federal Way PERMIT
COMMUMTY DEVELOPMENT SERVICES'}( (
33353 -835V fi AX 253- 097Y N L ,� 7 2' P P L I C A T I O N
FEDERAL WAY, WA 98063 -9718
'ww.cldn ederehant.e T OFFEDE�R�ApL�WAY
The following is reiliwa-�%�i7iltt!lioft'- an incomplete application will not be
SITE ADDRESS � \ (::) C\ C , a ' )
ASSESSOR'S TAX /PARCEL # L� Z� --:> - L �
LEGAL DESCRIPTION (e.g. Acme Estates, Lot I)
TYPE OF PERMIT
(Attach sepnmtepage%r lengthy legal description) .
PROJECT • •
SF MP CO ME EL PL DE EN FP
TD
rted. Please print iegibiy (in ink) or type.
SUITE /UNIT #
LOT SIZE (sj)
❑ BUILDING . ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING )<FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this Dermit onlu)
PROJECT NAME (Name of Business or Owner Last Name) \�,L Q.b
PEOPLE •- •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
tivJ c �1
r2S5)1-7'17V -5 2
MAILING ADDREM � � ,r CITY, STATE, ZIP
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
l�kl3 o.� l�v a
C
, STAT ZIP
Wt,
CELL PHONE
t,,3) -�`I()
1CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
1� "7 - 9 q - i Q �� � 0 -
{FAUX NUMBER -7 __v� // n1/,��,� 1
�3 )62� ltia.�33 ti
B L
NAME
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
E -MAIL ADDRESS
COMPANY NAME
APPLICANT NAME
OFFICE PHONE '
MAILING ADDRESS
CITY, STATE, ZIP
/CELL PHONE
t
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
NAME
PRIMARY PHONE
® - -7
E -MAIL ADDRESS
AME
MAILINO ADDRESS CITY, STATE, ZIP
•
EXISTING ASSESSED /APPRAISED VALUE $.
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE
ALUE OF PROPOSED WORK $
• TACOMA ❑ PRIVATE (WELL)
• PRIVATE (SEPTIC)
PROJECT •••
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
RT
NUMBER OF FLOORS I aausrtao I psorosau
*NEWHOMES ONLY** NUMBER OF BEDROOMS
Indicate number of each type of fixture to be
n[ra.�znaria.rai.
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS (or Tub /Shower combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Beau..- Sir k.1
TOTAL
ESTIMATED SELLING PRICE
or relocated as part of this project. Do not include existing
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
to remain.
GAS LOGS REFRIG. SYSTEMS
HOODS )commercial) WOODSTOVES
RANGES MISC (Describe)
GAS WATER HEATERS
WATER CLOSETS Roaeq MISC (Describe)
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
I cert#fy under penalty of perjury that 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 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
Sign u (Title)
RELATIONSHIP TO OJ T ❑ Owner-)o Agent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 — January 1. 2006 Page 2 of 4 kWandouts\Permit Application