05-101472.,m�
"'iWera' Way (,, � D PERMIT
`
COM-.,uffff DFV=PMEAff SERICIB
33325 DERAEAOE,WA9 SOUTH. 63 971 9778 p LI C ATI O N
FEDERAL WAY, WA 98063-9778
253-835-2607• FAX 253-8352609 MAR
www cilvoffederalwau.com
a a F MgfiP?Lk6 complete application will not be
The following is re.: - -" ,".. Y- �,-,rrr
5 _ b t ��
F CO E LGE EN FP
2ted, pleasel rant le ibin
p 9 _'J (
i�//1 SUITE/UNIT #
LOl�
SITE ADDRESS t7 `7 ! �D �/%j� T SIZE (sfl -!
ASSESSOR'S TAX/PARCEL # /(J L
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
µHuth sepanaiepage Jar lengthy legal dearnpron)
TYPE OF PERMIT (O/BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work =7tded on this wit A n1�� ^n �� �i L
PROJECT NAME (Name of J3- -n - or Owner Last Name)
PROPERTY
NAME
,rr���
u U)9 I&/1- L
7 "�
iV/J,
OWNER
v
MAIIdNG ADDRESS
P.b•f3oX
STATE,
a
CONTRACTOR
COMPANY
APPLICANT NAME OFFICE PHONE
-
/,NAME
4�:-
CELL PHONE
MAILING ADDRESS
CP1Y. STATE. Z1P
\
ES�IRATION
CIY''TOF FEDERAL VIAY BIJSII�TES�3LICENSE
j NUMBER DATE FAX NUMBER
B L EXPIRATION DAI
CONTRACTORS REGISTRATION NUMBER I—PY 0[ card required with "a h-PPHcaHon) /
— — — — — — — — — —
APPLICANT NAME OFFICE PHONE
APPLICANT
COMPANY �r
-
MAII.IlVG ADDRESS
CrIY, STATE, 71P CELL PHONE
( ) -
NUMBER
RELATIONSHIP TO PROJECT
o Architect o Tenant ❑ Agent ther
(Describ
CONTACT
NAME �
/�
MAB. ADDRESS
PRIMARY PH NE f� -� 1l E - c
,q5j
J�
LENDER
Lender information is
perRCW 19.27-09S.- m
AME /D
NAME-7'
7 , r
required ifprofect value exceeds $5,000
I
MAILING ADDRESSCITY.
3015513 a ' �f.S'e
STATE, ZIP
j�r��rn rt 9��Ds
PROPOSED USE /` -
ERIS1`IIQG USE 5eG r -
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK
YES
8rN0 FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? C YES ❑ NO
SPRMHLERED BUILDING? ❑
WATER SERVICE PROVIDER LAKEIIAVEN o HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
J
SEWER SERVICE PROVIDER gAdd&HAjTN 0 HIGHLINE ❑ PRIVATE (SEPTIC)
ca
a
Value of Mechanical Work
REFRIG. SYSTEMS
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS LOGS
HOODS (co��.q
WOODSTOVES
MISC (Desenbe)
BBQS
BOILERS
FANS
FIREPLACE INSERTS
RANGES
t3AS WATER HEATERS
PLAN?
C GE OF USE? a YES
COMPRESSORS
FURNACES
GAS PIPE OUTLETS
UP/SEPA/SU? a YES
DUCTS
NEW ADDRESS REQUIRED?
o YES o NO
DEMO PERMIT REQUIRED? a YES
PLUMBINGSHOWERS
f
WATER CLOSETS �q
MISC (Describe)
BATHTUBS laTunlsuo—cabq
-
SINKS
DRINKING FOUNTAINSDISHWASHERS
SYST
aE�-
GAS PIPE OUTLETS
SUMPSjRAINWATER
HOSE BIBBS
WASHING MACHINES
URINALS
_ N ALS rn�wvcva
-- ELECTRIC WATER HEATERS
ormation furnished 6y me is tract and correct to the best of my knowledge, and further, that I
I certify under penalty of perjury that the
iinjor anperform the work for true
eh the permit application is made. I further agree to hold
am authorized by the owner of the above Ps' fees incurred in the investigation and defense of
harmless the City of Federal Way as to' any clatin (incbuding costs, expenses, and attorneys! f o Federal Way, but only where such claim
including the undersigned, and.iled against the City f lied to the city as a part of
such claim), which may be made by any Person, ee upon the accuracy of the in
supplied
arises out of the reliance of the city, including its officers and employees, Po
this application. S /%
' DATE �``,
NAME/TITLE fro )
RELATIONSHIP TO P OJF.CT l ❑ Ownei gent ❑ Contractor ❑ Architect ❑ Other
FOR OFFICE: USE ONLY
TENANT IMPROVEMENT
NEW o ADDITION
o ALTERATION
o REPO ❑
a YES
a NO
o
BUILDING SHELL ONLY?
❑ YES ONO
PLAN?
C GE OF USE? a YES
o NO
ZONIlYti DESIGNATION
UP/SEPA/SU? a YES
o NO
NEW ADDRESS REQUIRED?
o YES o NO
DEMO PERMIT REQUIRED? a YES
o NO
PLATTED LOT?
❑YES o NO
Bulletin if100 — August 19, 2004
Page 2 of 4 k\Handouts\Permit Application
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