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3332S8xAVERUB SOUTH • PO BOX 97 E 2 Q APPLICATION
FBDBRU WAY, WA 98063 -9718
759 -US -2607- FAX 253- 835.2669 f F
CITY OF FEDERAL WAY
The following is requ 0 ifii IT an incomplete application will not be accepted Please print. legibly (in ink) or type.
SITE ADDRESS > jq ye
ASSESSOR'S TAX /PARCEL Ii
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
SUITE /UNIT #
LOT SIZE (s)
(�+�•aroelh•�d6Vr�d..11 U
PROJECT VA •• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION 13 ELECTRICAL ❑ ENGINEERING XFIREPREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on
PROJECT. NAME (Name of Business or Owner
PROPERTY
OWNER
CONTRACTOR
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME
PRIMARY PHONE
Are a
0 )M -
MAl)UNO ADDR u43 441
CITY, STATE, ZIP
E -MAIL ADDRESS
L
I nay
COMPANY NAME
�
APPLICANT NAME
OFFICE PHONE
(/ _ a vW
V
CITY, STATE, ZIP
/ -TM
MAILIIJO ADDRESS
TYfAZ, 21P
C&LL PHONE
- Z
F F D RAL WAY BUSINESS LICENSE NUMBER
'EXPIRATION DATE
FAX NUMBER
CONTRACTOR'S RE(}IBTRATION NUMB24
EXPUIATION DATE
E-MAIL ADDRESS
COMP "F
APPLICANT NAME
OFFICE PHONE -
MAIUNO ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT j
11 Architect ❑ Tenant 13 Agent Ca.l
FAX NUMBER
.Other rf ,
NAME PRIMARY PHONE �1i E -MAIL ADDRESS
- 4 7%2
NAME
PerRCW 19.28095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $_ , C)C'
SPRINKLERED BUILDING? o YES O NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES O NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN O HIGHLINE ❑ TACOMA O PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
PROJECT ••-
AREA DESC ON
BASEMENT
AREAS
EXISTIN
PROPOSED
FT.
TOTAy
S . FT.
FIRST
FANS
GAS WATER HEATERS
'-CIO
MISC (Deacnbe)
SECOND
FIREPLACE INSERTS
HOODS (cO-
THIRD .
FURNACES
RANGES
o NO
ADDITIONAL FLOORS (DESCRIBE)
GAS LOG SETS
REFRIO. SYSTEMS
UP /SEPA /SU?
DECK (0 COVERED OR 0 UNCOVERED ?)
ONO
PLATTED LOT?
o YES o NO
GARAGE 0 CARPORT 0
LAVS (srt.=ab*4
URINALS
MISC (Describe)
NUMBER OF FLOORS
RAINWATER SYST
VACUUM BREAKERS
7or4camrravm
rorecraaroesos.
rormsr
•`NEW HOAM ONLY".. NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
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 $ (A COPY OF BID OR ESTIMATE MUST BB INCLUDED WITH APPLICATIOA7
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS
WOODSTOVES
BBQ3
FANS
GAS WATER HEATERS
'-CIO
MISC (Deacnbe)
BOILERS
FIREPLACE INSERTS
HOODS (cO-
COMPRESSORS
FURNACES
RANGES
o NO
DUCTS
GAS LOG SETS
REFRIO. SYSTEMS
UP /SEPA /SU?
o YES
ONO
PLATTED LOT?
o YES o NO
BATHTUBS (or'Nb /si..c.b4
LAVS (srt.=ab*4
URINALS
MISC (Describe)
DISHWASHERS
RAINWATER SYST
VACUUM BREAKERS
DRINKING FOUNTAINS
SHOWERS
WATER CLOSETS Iraq
ELECTRIC WATER HEATERS
SINKS
WASHING MACHINES
HOSE BIBBS
SUMPS
1 certVY under penalty of perjury that I am the property owner or authorised agent of the property owner. I c*nVy that to the best of my
knowledge, the irfermation submitted in support of this permit application is true and correct. I eert(/yi tea! I will 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 local, state, or federal laws regulating construction or environmental laws.
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, but only
where such claim arises out of the reliance of the city, including its officers and employees, upon•the accuracy of the hi formation supplied to
the city as a part of this application.
SIGNATURE:
Owner
o NEW o ADDITION
o ALTERATION
o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY?
o YES. o NO
BASIC PLAN? '
o YES
o NO
ZONING DESIGNATION
CHANGE OF USE?
o YES
o NO
NEW ADDRESS REQUIRED?
o YES o NO
UP /SEPA /SU?
o YES
ONO
PLATTED LOT?
o YES o NO
DEMO PERMIT REQUIRED?
o YES
o NO•
Bulletin it 100 "August 16, 2007 Page 2 of 4 . klHandouts\Permit Application .