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93395 aTM AVBNUB SOUTH • 63 971 9718
ABDBRALWAY, WA 98063- 9718" A PLIJ�CATION ss3 ass 2607• PAX953 83sy?4�� Y FE !� E R
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The following is required infornC&Q& an incomplete application will not be accepted. Please print Ug o4r (in inN or type.
PROPERTY • •
SITE ADDREss + S '5- 3 A-vx SUITE /UNIT #
ASSESSOR'S TAX /PARCEL #
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
LOT 8= (3j)
(+�mpa�rWjbrW*w load dmateuoW
PROJECT •• •
TYPE OF PERMIT Q BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION IJ tiMECTRICAL ❑ ENGINEERING PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this hermit onl l
4k'�t� ► 5�r� ors � t��.;D � 5 w� c�r'�= 0 51�: o �F1�- �
PROJECT NAME (Name of Business or Ounw Last Name) _ w U o . l _s�:) V i S 1 Z
PEOPLE INFORMATION
PROPERTY
OWNER
CONTRACTOR
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME
PRIMARY PHONE
MAILING ADDRESS
CCIY, STATE, ZIP
E-MAIL ADDRESS
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
F'SW
T-' �
(?-5s ) C? 3- 1 L
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
'2 \'I
FAX NUMBER
( zSi 7s`2 - a
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
(2:E3
ONTRACTOa's H TION xuKaR
ExPmTION DATS
E-MAIL ADDRESS
r F\q,eSW-T- -c SS- LLJ
F LNo- –Qe-
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
S ^MME A S cp . -
PHONE
( ) -
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
-
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant 0 Agent o Other
NAME Ir— Iii i.� ARIMARY PHONE E MAI. ADDRESS
v 2 53 2022- - -70,-t(
NAME
Per RCW 19.27.095.
Lender in ornuttion is required if project .value exceeds $5,000
MAILINO ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE
EXISTING ASMSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 1 6 �I LAO
BPRINKLERED BUILDING? ❑ YES a NO FIRE, SUPPRESSION SYSTEM PROPOSED /REQUIRED? a YES o NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN O HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGELINE ❑ PRIVATE (SEPTIC)
0 to-1 071Y49
r.
cow,
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
SO. FT.
TOTAL
S . FT.
BASEMENT
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
FIRST
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
SECOND
HOODS (Commerdop
-
FURNACES
THIRD
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
ADDITIONAL FLOORS (DESCRIBE)
a NO
PLATTED LOT?
a TES o NO
DECK (❑ COVERED OR ❑ UNCOVERED ?)
DEMO PERMIT REQUIRED?
a YES
o NO
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
mxnro
M010dXo
TOTAL
rorscsmwer
ve
rorALnmroswar
Toracer
* *NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate. number of each type of fEdure to be installed or relocated as part of this project. Do not uichtde existing factures to remain.
IECCEL4HICAL
LAVS I sme,l
URINALS MISC (Describe)
Value of Mechanical Work $
(A COPY OF BID OR ESTIMATE MIST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
BBQS
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
FIREPLACE _INSERTS
HOODS (Commerdop
COMPRESSORS
FURNACES
RANGES "
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
G
BATHTUBS (or Tub /showw coma*
LAVS I sme,l
URINALS MISC (Describe)
DISHWASHERS
RAINWATER SYST
VACUUM BREAKERS._
DRINKING FOUNTAINS
SHOWERS
WATER CLOSETS Irwwq
ELECTRIC WATER HEATERS
SINKS
WASHING MACHINES .
HOSE BIBBS
SUMPS
o YES
Jr cerab under pesky of perjury that ! am the property owner or authorised a9ent of the property owner. I onto that to the best of my
knowtedge, the bVernmtlon Submitted in support of this permit application is trus and correct I cert(jy that I wdU comply with all applicable
City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. I understand that the issuance of this permit
does not remove the owner's responsibility for compliance with toeat, state; or federal taws regulating construction or environmental laws.
I further agree to hold harmless the City of l tderat Way as to any claim (lnctuding costs, expenses, and attorneys' fees incurred in the
investigation and defense of such elatml, which may be made by any Person, including the undersigned, and Plod against the city, but only
whom such claim arises out qf the roUance of the city, including its o eers and smployoes, upon the accuracy of the information supplied to
the city as a part of the alrpjtioy\
SIGNATURE: DATE
pertp Owner and /or Authorized Agent
a NEW a ADDITION
o ALTERATION
a REPAIR a" TENANT IMPROVEMENT
B=DING SHEM ONLY?
a YES o NO
BASIC PLAN?'
o. YES
o NO
ZONING DESIGNATION
CEEANGE OF USE?
o YES
o NO
NEW ADDRESS REQUIRED?
a YES a NO
UP /SEPA /SU?
o YES
a NO
PLATTED LOT?
a TES o NO
DEMO PERMIT REQUIRED?
a YES
o NO
Bulletin #100 W, y >4 Page 2 of MandoutAPermit Application
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