09-104995r
Federal Way Z-
d
COM1d W1YDE1V1,- 111SER1=QE'C 0 3 209 PERMIT SF MF CO ME EL PL DE EN F
33325 BTMAVENUE SOUIfl • PO BOX 971 S ` T
FEDERAL WAY, Sg� � ��� f`/�,/''j{l,,J
259 -635 -2607• F V -\ Q T �,T
i ,,,, , N .. r. ae: i�9_ ` l 1T1 O 1 r /
ThefolLowing is reouired in oi7n3iiort _ an incom fete tication will not be accepted. Please Print to t
1 ` � (zn ink) or
SITE ADDRESS 1 "1 0 "l S, 0 t r
SUITE /UNIT # 'D
ASSESSOR'S TAX /PARCEL # Z _ Q LOT SIZE (so
LEGAL DESCRIPTION leg. A-w Estates. Lot 1) (q E Ajc-"— i C-- S 'iegiL- v r---r
UU=k P9x.r -kngft Lval des -0-V
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
D DEMOLITION E3 ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detaz7ed description of work included on this Hermit_ ontu)
PROJECT NAME (Name of Business or Owner Last Name) —� �� `' -r
PROPERTY NAME
OWNER rA nA-`
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
3
CONTRACTOR'S REGISTRATION NUMBER( B L
pp of card tn4uirni
aC, fI`r0-zi,,-xL,
OLe
-130 6i
Ze'Q (RAJ L i--�
STATE. ZIP
706 ) 57y - 0%
`706
EXPIRATION DATE FAX NUMBER
--7 /(3 r'Z-o (1
C. STATE, ZIP ti.. �_ i I r v r nsxnnro
❑ Architect ❑ Tenant 00"Iige FAX NUMBER
nt ❑Other (Describe) � ) _
Per VW 19.27.095: Lender 1bfD1r1natiQn is NAME
regUlred ifPr Qj-a - a[ue. ---ls $5.000
EXISTING ASSESSED /APPRAISED VALUE $
SPRINKLERED BUILDING? YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER O LARFFIAVEN
/^
� PROPOSED USE _k.
'^ VALUE OF PROPOSED WORK $ , ,'ZQ 0 : bc,
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES �>&o
0 HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE iSEPTICI
C.d M
Indicate number of each type of fixture to be installed or relocated as
part of this project Do
existing futures to mnain
MECELAWCAL
❑ NEW ❑ ADDITION
❑ ALTERATION
Value of Med=ical Work $
BUILDING SHELL ONLY? ❑ YES ❑ NO.
EASIC PLAN?
AIR HANDLING UNITS
EVAPORATIVE COOLERS
dAS LOGS
REFRIG. SYSTEMS
BOIL
BOILERS
FANS
HOODS tcnmmemeU
WOODSTOVES
FIREPLACE INSERTS
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
GAS WATER HEATERS
o NO
DUCTS
GAS PIPE O
❑ YES
o NO
BATHTUBS (o T b /M...,combo) SH a WATER CLOSETS trweo MISC (Describe)
DISHWASHERS DRWMG FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS tsatbroaml ' VACUUM BREAKERS ELI=RIC WATER HEATERS
I certify unde pity ofpojury that the information furnished by me is true and correct to the best of my know•
am authorised by the owner of the above premises to age, and further, that i
harmless the City of P decal W as to perform the work for which the permit application is made. I further agree to hold
ay any claim ruwluding costs, rspenses, and attorneys' fees incurred in the investigation and defense of
such chin, which may be made bg any person, including the undersigned, and filed against the City of Federal Way, but only where such claim
thisarises
applicatio
o m reliance of the city, including its offters and employees, upon the accuracy of the information suppiied to the dty as a part of
NAME /TITLE A4, DATE
(Si ) [Rtle)
RELATIONSW PRO.IECT ❑ Owner ❑ Agent Contractor ❑ Architect ❑ Other
;:2'Lx S7i;Ir�C:L,iJ5E ONLY' _
❑ NEW ❑ ADDITION
❑ ALTERATION
❑ REPAIR ❑ TENANT EMMOVEMENT
BUILDING SHELL ONLY? ❑ YES ❑ NO.
EASIC PLAN?
YES
❑ NO
ZONING DESIGNATION
CH�411TGE OF USE?
o YES
❑ NO
NEW ADDRESS REQUIRED? ❑YES C1 NO
UP /SEPA/SU?
v YES
o NO
PLATTED LOT? o YES ❑ NO
I DEMO PERMIT REgUIRED?
❑ YES
o NO
iary I, LUUb Page 2 of 4 MI'iandoutsTermit Application