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Federal Way 'nJEC Zoog PERMIT
COMMUMTYDEVELOPMENT SERVICES
33325 8 -AVENUE SOUTH. 63 BOX 9718
pLI CATI O N
FEDERAL WAY, WA 9'053-8 3 -194Y O F FEDERAL `r
253-835-2607• FAX 253-835-
wwwcituo(federalwaucom BUILDING DEPT..
The following is
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SITE ADDRESS D �,' o 2 / 4vr, , Su '
not be
ASSESSOR'S TAX/PARCEL # — - —
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for lengthy legal descriptfoN
PROJECT• ' •
- � C, (0
SF MF CO ME EL PL DE EN FP
r / - / I
ted. Please Print legibly (in ink) or type.
SUITE/UNIT #
LOT SIZE (sf)
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING IX FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
I it ,,.1C, ,Le 61A)o U- 1. • _ 300 4'-yC 5.�/�OrCSS�'o nj
A �. ? f C -) LA -1,. 366 S�s��•�r
PROJECT NAME (Name of Business or Owner Last Name) AThe 4r, 6 t
PEOPLE•• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
4S 0 -i (
MAILING ADDRESS CITY. STATE, ZIP
?. o. Q o)c 60 -se :i 3 ?0 �
COMPANY NAME
APPLICAN-1 NAME
OFFICE PHONE
(34b ) 5.� 1 a783
W/G (y S A -re &,-
-S40-AG o.,,rwte4*)
(160 ) F.1 I - .2�(�3
MAILING ADDRESS
CITY, STATE. ZIP
CELL PHONE
t?.173
BA-Wf- f rou��d �,1w ti&6
( )
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent
o Other (Describe)
( )
--B
L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application)
EXPIRATION DATE
/ /) bo
eL t S E r ,- F 3 7 3®
K
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COMPANY NAME
APPLICANT NAME
OFFICE PHONE
Wes r� s�wk�s r -{
k Ga"NI�
(160 ) F.1 I - .2�(�3
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
0 • ISO-/ I l 7'3
1n►u—d LIP, (.o
( )
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent
o Other (Describe)
( )
NAME PRIMARY PHONE - I E-MAIL DRESS
( ) _ W S W 1E
Per R(:LY .19.27.098: Lender b1forniatiori is NAME
re0r'edifl0rn ect value cc'e04$6;060
MAILING ADDRESS CITY, STATE, ZIP PHONE
( )
EXISTING ASSESSED/APPRAISED VALUE
PROPOSED USE
VALUE OF PROPOSED WORK
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
Indicate number of each type of fixhlre to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work $
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS (orlwb/Shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Bathroom Sinks)
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (Com—reiai)
RANGES
GAS WATER HEATERS
WATER CLOSETS ('toilet)
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I cert(f / under penalty of perjury that the irtformation 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 claintl, which may be made by any person, including the undersigned, and filed 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 T �G�- I! w— DATE
(Signature) (Mite)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent q'/Contractor ❑ Architect ❑ Other
Bulletin #100 - January 7, 2005 Page 2 of 4 k\Handouts\Permit Application