07-104685cm or
Fed era I!ay „G 2 3 200 PERMIT
COMMUNITYDEVELOPMENTSNCEs SF MF CO ME EL PL DE E FP
93925BTMMWA SOUTH•PO BOX 9718 �� 'PLI CATI ON
FEDERAL WAY, WA s o F FEDERAi-
259- 39 mo7• FAX 2 - �1 pq 9
ww 6e4i
The following is required information - an incomplete application will not be accepted. Please print IVMly (in ink) or type.
SITE ADDRESS - 1 q 3 5 . 34 gT`� Tn. -r SUITE /UNIT # O
ASSESSOR'S TAX /PARCEL # _ - LOT SIZE (sffl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
.. (Attach sep.— pwefa lergft Ival desaW.W
PROJECT INFO* • •
TYPE OF PERMIT D BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING 'I= PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
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PROJECT NAME (Name of Business or Owner Last Namel /j� GV COQ T (Jkf �GIy
PEOPLE •• •
PROPERTY
ME �
.PRIMARY PHONE '
MAILING ADDREESS� p
822 f LAA PLWDE &av f of
OWNER
l l.�
(qz,,r - 4100
- EXPIRATION DATE
FAX NUMBER
B, NG ADDRESS -qq{��
i5' W
CITY, STATE, r�ZIP pQ����
- �MWV'� Iw�
E -MAIL ADDRESS
CONTRACTOR'S REGISTRATION NUMBER
PR�l �S 973 PkA
CONTRACTOR
COPY of card required ter,
with each application L�
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
COMPANY NAME
f�irt� F Cam-
APPLICANT NAME
6VI-A4 ►J
OFFICE PHONE
(?mb )7'$k -3806
MAILING ADDREESS� p
822 f LAA PLWDE &av f of
CITY, STATE, ZIP
1<7VA- ” 1.i� LC��ZT
CELL PHONE
(� ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
- EXPIRATION DATE
FAX NUMBER
20 -oz - tOSW 9 7
FAX NUMBER
(ZO(a ) 7 z - $j(ca
CONTRACTOR'S REGISTRATION NUMBER
PR�l �S 973 PkA
EXP TIO DATE
I,
E-MA ADDRESS
6;me'&-
.10130107
e7-
COMPANY NAME
FAQ Flu fi S�5
APPLICANT NAME
�� �sTM4
OFFICE PHONE
(2 �) 79f -38'06
MAII.ING ADD S -
CITY, STATE, ZIP
CELL PHONE
PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant o Agent ❑ Other ConnTh °►� Z
(Z,OG )'Zl - $"( (00
MME PRIMARY PHONE E -MAIL ADDRESS
_T_(M&si"wI A�J (�o`) 88 - 380 fS . 3
NAME
Per RCW 19.27.095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED /APPRAISED VALUE $_
SPRINKLERED BUILDING? o. YES o NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVEN
PROPOSED USE
VALUE OF PROPOSED WORK
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? o YES o NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
o HIGHLINE ❑ PRIVATE (SEPTIC)
0 PROJECT ..•
AREA DESCRIPTION
AREAS
MaSTING
8 . FT.
PROPOSED
S . FT.
TOTAL .
8 . FT:
BASEMENT
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
FIRST
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
SECOND
HOODS (Cortm,erclaq
COMPRESSORS
FURNACES
THIRD
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
ADDITIONAL FLOORS (DESCRIBE)
D NO
PLATTED LOT?
❑ YES D NO
DECK (❑ COVERED OR ❑ UNCOVERED ?)
DEMO PERMIT REQUIRED?
D YES
D NO
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
RX`BITIG
�oroem
TOTAL
WTAL SUMBi'
T TorurxoPOS�se
rornesr
"ATEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
N FIXTURES
Indicate number of each type off vture to be installed or relocated as part of this project Do not include existing fixtures . to remain.
MECHANICAL
LAVS (Bathroom Sinks)
URINALS MISC (Describe)
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 (Cortm,erclaq
COMPRESSORS
FURNACES
RANGES
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
PLUMBING
BATHTUBS (or Tub /Shower Combo)
LAVS (Bathroom Sinks)
URINALS MISC (Describe)
DISHWASHERS
RAINWATER SYST
VACUUM BREAKERS
DRINKING FOUNTAINS
SHOWERS
WATER CLOSETS (Touet)
ELECTRIC WATER HEATERS
SINKS
WASHING MACHINES
HOSE BIBBS
SUMPS
❑ YES
1
i certify 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 aboue p emises to perform the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way as, an claim (including costs, expenses, and attorneys' fees incurred in the investigation and defense of
such claim), which may be made by it, including the undersigned, and f led against the City of Federal Way, but only where such claim
arises out of the reli a c' its oIj icers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME /TITLE DATE 3 �2 7"V %
RELATIONSHIP TO PROJEC ❑ Owner ❑ Agent ❑ Contractor o Architect ❑ Other
-
o NEW ❑ ADDITION
D ALTERATION
D REPAIR D TENANT IMPROVEMENT
BUILDING SHELL ONLY?
D YES D NO
BASIC PLAN?
D YES
D NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
❑ NO
NEW ADDRESS REQUIRED?
D YES D NO
UP /SEPA/SU?
o YES .
D NO
PLATTED LOT?
❑ YES D NO
DEMO PERMIT REQUIRED?
D YES
D NO
#100 — January 1, 2007 Page 2 of 4 k\Handouts\Permit Application