07-102778Ak RECEI\fv
CITY OF
Federal Way qAY 2 2007 PERMIT
cOMMUNITY DEVELOPMENT SERVICES
33325 8111 AVENUE SOUTH • 63 BOX 9718 L I G A T I O N
FEDERAL WAY, WA 98063-9718 _
• 253-835-2607• FAX 253-V.00"I 091 �EC(�0, D D
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SF MF CO ME EL PL DE E FP
SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # —1-3 —Z- LOT SIZE (s])
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
/Attach separate page for I—Ohy legal desa*Ua J
■ ' PROJECT INFORMATION '
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
lit
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
•OWNER
CONTRA OR
APPLICANT
CONTACT
"
.. ,. :... , . PEOPLE INFORbIATION , .. .
NAME PRIMARY PHONE
MAILING ADDRESS CITY, STATE, ZIP
COMPANY NAME
` &Nv-'�'So� S '�'�
APPLICANT NAME
'DPV& Cod r"ts("'j
OFFICE PHONE
(N. ) ;! o
MAILANO ADDRESS
CI� TATE, ZIP
ELL PHONE
-
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER P TION DATE
1 9 - `� - i �' -� � 1. `31 ��`�
FAX NUMBER
(��() '34
- � 3&1
L
CONTRACTOR'S REGISTRATION NUMBER copy o[ card required with each appllc on)
L� N _ (�- _�
EXPIRATION DATE
/ ��,
COMPANY NAMEAPPLICANT
NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
(CELL PHONE
)
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant Agent ❑ Other (Describe)
NAME PRIMARY PHONE E-MAIL ADDRESS
USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? d YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 PRIVATE (SEPTIC)
FIRST
SECOND
THIRD
FOURTH
FLOORS
DECK(COVERED7)
GARAGE ❑ CARPOF
NUMBER OF FLOORS
"NEW HOMES ONLY"*
�I
AREA DESCRIPTION
I•
=STING I raoroeso
3F BEDROOMS
Indicate number of each type of fixture to be installed or
Value of Mechanical Work $
TOTAL
ft
EXISTING
SO. FT.
SELLING
as part of this
PROPOSEDI TOTAL
SO. FT. SO. FT.
Do not include existing fixtures to remain.
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
BBQS
FANS
HOODS )commercial)
WOODSTOVES
BOILERS
FIREPLACE INSERTS
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
GAS WATER HEATERS
DUCTS
GAS PIPE OUTLETS
PLUMBING
BATHTUBS )or Tab/Sbowercombo)
SHOWERS
WATER CLOSETS rroiieq
MISC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPE OUTLETS
SUMPS
RAINWATER SYST
WASHING MACHINES
URINALS
HOSE BIBBS
,VAVS (bathroom Sink)
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I certify under penalty of perjury that the information 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 claim), which may be made by any person, including the undersigned, and flied 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 apart of
this application.
NAME/TITLE DATE /~
(Signature (Title(
RELATIONSHIP TO PROJECT Q Owner l7 Agent ❑ Contractor ❑ Architect ❑ Other
Rnllmin ;H1 A0 - iannary I 71)n6 Page 2 of 4 k\Handouts\Permit Application