06-103479un Of �' V ..
FederalwaIREcEIVL PERMIT
COMMUNINDEVELOPMENT SERVICES
33325 FEDERAL WAY,, WAA9980�_ ' 4 zoo p p LI CATI O N
2S3 -83S -2607• FAX 2S3- 835.2609
1
www.citmoffedendwau.com '
CITY OF FEMERAIWIAY
The following is rQUjbW n - an incomplete application will not be
1. -J_ 3_Z
SF MF CO ME EL PL DE EN
accepted. Please print legibiu fin inkl or tune_
SITE ADDRESS _
40pr SUITE /UNIT # I
ASSESSOR'S TAX/PARCEL #
LOT SIZE (s,)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Aaarh sep le page f- kvft legal desoowq _
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING Q�FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlul / \
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE* •- •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME
PRIMARY PHONE _
MATLING AD CITY, STATE, ZIP
COMPANY NAME
APPLICANT NAME
APPLICANT NAME
i
OFFICE PHONE
O DRESS
'
� A E, P
CELL PHONE
L P
CELL PHONE
It
F FIIERAL WAY BUSINESS
LICENSE NUMBER
c
P[RAT[O DATE -
'FAX NUMBER
El
L
CONTRACTORS REGISTRATION NUMBER (eopy of cud required with each application)
EXPIRATION DATE
COMPANY NAME _
APPLICANT NAME
OFFICE PHONE
`'r1 {.:+1- • \ .a X1,'1 . =7-:a ,; #--�`- • `; �
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�- ,
MAILING ADORES 4
_
A , Z P _
L P
CELL PHONE
It
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
NAME PRIMARY ONE E- MAILADDRESS
-�
EXISTING ASSESSED /APPRAISED VALUE $
SPRINKLERED BUILDING? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVEN
PROPOSED USE
VALUE OF PROPOSED WORK l
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ IIIGHLIHE ❑ 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 EVAPORATIVE COOLERS GAS LOGS REFRIG. SYSTEMS
BBQS FANS HOODS (commem WOODSTOVES
BOILERS FIREPLACE INSERTS RANG MISC (Describe)
COMPRESSORS FURNACES WATER HEATERS
DUCTS GAS PIPE OUTLETS
BATHTUBS (or Tub /shower combo(
DISHWASHERS
GAS PIPE OUTLETS
WASHING INES
LAVS (Bath..31alco
SINKS
SUMPS
URINALS
VACUUM BREAKERS
WATER CLOSETS (Toilet)
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
MISC (Describe)
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 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 flied 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 �N�.� -.�� i' ,X-C_T De S I nxsCL DATE -T - Af - o C{
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent Contractor ❑ Architect ❑ Other
Bulletin #100 - January 7, 2005 Page 2 of 4 MandoutsTermit Application