93-102987 . 6 5Z1.0695 P. 02
SENT BYtDEPT, OF COMMUNITY DEV; 8-1683 ; 1 :30PM i CITY cr FEDERAL WAY$ 5315555;4 2
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Permit #_15L-D43-Ia s:�
CITY OF FEDERAL WAY "t I D9•O
T BUILDING PERMIT APPLICATION ot3_1 (mgkd(
-- — .... —. —Please Priv; —
EaX 1 'ENANT NA'vl , - r _ ----•----- -------
OWoiER S AOORESS.. cL.
-— CITY 12E-L,' _(4JJ J R..
Ps-IONc
I}FSCRIi3EJoe _ Lk 7. C.L. t'" AS ,''r -T e_ _. z __ _� 7 - L6 ' '
THE PROPERTY IS OWNED BY: S;NGLE/MAPAIED PARTNERSHIP - CORPORATION ___ ____
BOX 2 CONTRACTOR'S NAME 1914 r P,Ls,.11 = L 7 _ �yi CONrAACTOR'S REG. #19-j11e -N so,F3/4:5-
Card MUST re presenicd
CONTRACTOR'S ADDRESS , -4. C _rz. T. t ci ' CITY_7 .,C..Ci. ,9 PHONE 5, --/,
EXPIRATION DATE .__:_i_':.�? _..24(_.:__` ------
- OR---
I HAVE READ CHAPTER 18.27,010 RELATING TO DEFINITIONS OF GENERAL CONTRACTORS AND SPECIALTY CONTRACTORS AND
CHAPTER 18.2E.110 WHICH PROHIBITS ISSUING PERMITS WITH_OUT PROOF Or REGISTRATION.
BOX 3 CONTACT PERSON w.F`'e_-�:,<_t.Pic_z'T PHO E A " --_ _
- - PHONE •->' -✓._
R(}X d SEWER DISTRICT .:.Y....
- - -- - WATER DISTRICT _- _ __
BOX 5 ESTIMATO PROJECT COST -_ _�_ EXISTING BUILDING VALUATION ^- _- _.
50K @ PROPERTY TAX ACCrJUt.T iNUhfSER__ ? Q,T. —�.-
LEGAL DE$C°Ir TION .,._ _..n_,....._�
(If;1ece ry, please subtrir a Separate page with the legal pescrJpiltlr.) ,,_,
K,C, Plat Recerdlog #
BOX 7 BUILDING SQUARE FOOTAGE:(Exlstin iPro aced 1ST FLOOR - / - _
P ) 2ND FLOOR _ !
3RD FLOORBASEMENT— _ GARAGE
�...�....!_ DECK I_
BOX 8 ( ) SINGLE FAMILY ( ) NEW CONSTRUCTION
( ) MUIJIFAMfLY (NO, OF UNITS = __) ( ) EXISTING 6TR'JCTURE
( ) COMMERCIAL/INDUSTRIAL TOTAL AREA OF PROPERTY __SOFT
OI?X 9 PLUMBING FIXi-Ui eS (including rough-Ins) ��—MECHANipAL APPLIANCES---- BASIC FEE S
NO.. �WATERCLOSETS GAS PIPING, FEET___ (p $
BATHTUBS NO.—_.. FURNACE, ELK. GAS $ _
SHOWERS .... GAS HOT WATpl'! HEATED — $ — _
--LAVATORIES CONVERSION BURNER $ ___
_ SINKS BOILER, SIZE,_.:_ BTU $ __ . .
DISHWASHERS _ AIR HANDLING UNITS $ _v __
...,..:._._..ELECTRIC HOT WATER HEATER _HEAT PUMPS, SIZE _________ $ __
LAUNDRY WASHER OUTLET .....,UNIT HEATERS $ ___A
__,_...__,._..URINALS AIR COOLING UNITS, SIZE - $ - _-
DRINKING FOUNTAINS COMMERCIAL HOOD $
-_- -SUMPS, SPRINKLER VACUUM BREAKERS OTHER $
_� _.OMNI ..,.r,...., _ $ -- ,
4.,.. TOTAL FIXTURES .�._ �..._s._-� --, $ _ ,_.,...._..
_ - $
_
I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND CORRECT TO THE BEST DF MY KNOWLEDGE
AND FUR f HER THAT)AM AUTHORIZED BY THE OWNER OF THE ABOVE PREMISES TO PERFORM THE WORKFOR WHICH PERMIT APPLICATION IS
MADE,I FURTHER AOREE TO SAVE HARMLESS THE CITY OF FEDERAL WAY AS TO ANY CLAIM(INCLUDING COSTS,EXPENSES,AND ATTORNEYS'
FEES INCU; RED IN INVESTIGATION AND DEFENSE OF SUCH CLAIM),WHICH MAY S5 MADE 13Y ANY PERSON, INCLUDING THE UNDERSIGNED,
AND FILED AGAINST THE CITY OF FEDERAL WAY, RUT ONLY WKCI g gUCI-I CLAIM AAI OUT OF THE RELIANCE OF THE CITY,INCLUDING ITS
OFFICERS AND EM,PLOYEES, UPON THE ACCURACY OF THE INFORMATION SUPPLIi O TO THE CITY AS A PART OF THS APPLICATION,
$W'4 AOE�IT: II( '"L4::6 .i i:7 3- r„rEi}-t1_A,aniDATE: _ --), r
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