06-101189 = F � � ��������
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��TM°F�'� MAR 1 3 2006 � - � � � � �
Federal W �
• COAIANMIYDSVBLOPLENf��,�s P E R M�'�
933T58TMAVSM/BSOUTF!•POBOX9718 C UF FEDEHAL WAYSF MF CO ME EL PL DE FP
253-835-26p7•FAX�53-835-Z609 A P P L I C A T�`�� D E PT.
FSDSRAL WAY,WA 98063-9718.
un u w,d i uo/fe de mlu�a u.m m
T.he oliourin ts re utred tn ormatlon-an inco lete ap iication wiiI not be accepted. Piease rtnt ieg{6Iy tn�nkJ or ty e.
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SITE ADDRESS - �� C : �C f �^ i' �(; .fiVl � (,�.J 8UITE/UNIT#�
AS3ESSOR'S TAX/PARCEL# _ _ _ _ _ _- _ _ _ _ LOT SIZE(sfl
LEGAI.DESCRIPTION(e.g.Acme Estates,Lot 1 J
' . (Aaach+mnmtav�I���8'�hv tega!dea'xiatton) �
'• • • •
TYPE OF PERMIT ❑BUILDING . ❑ PLUMBING ❑ MECHANICAL
❑ DEM�LITION ❑ ELECTRICAL ❑ ENC�INEERING�FIRE PREVENI'ION SYSTEM
P, OJECT DESCRIP�TION(Provide detailed des ' tio f work included on this vermit onlu) ,
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, PROJECT NAME(Name of Business or Owner Last Namej _��_��,�'
• • • - •
PROPERTY NAME PRIMARY PHONE
OWNER f � � � _
MAI�D SS ^ / CITY.�TE,ZIP � ���
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� CONTRACTOR COMPANY N E , APpLI NAME OFFICE PHONE
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MAILINO ADDRESS� 3TATE,ZIP CELI.PHONE
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CITY F ERAL WAY BUSINES3 LICEN3E NUMBER EXPIRA ]ON A E FAX NUMHER
. ��-- �� - --B L � � �� 3� �� � � -
CONTRACTORS REC3I3TRATiON NUMBER(copy ot card reqnired with each�ppllntloa) EXPIRATION DATE
�L. �- 1� ' � � o .� � � r 5 � � �
APPLICANT �MP�NAME APPLiCANT NAME ORFICE PHONE ' -
�'��1�ti � � )
MAILINO ADDRE33 CITY,STATE,ZIP CELL PHONE'
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RELATIONSHIP TO PRW ECT FAX NUMBER
o Architect ❑Tenant ❑Agent o Other(Describe) ( � _
CONTACT NAM ' � PRIMARY PHONE E-MA[L ADDRESS
� �� rti �'�v� �1 - • c��b� 3. -5 Yy �
LExnER N�M� �
MAILINO ADDRESS C(TY,3TAT8,ZtP PHONE
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I � � : , • . • �
EXISTING U3E PROP03ED II3
EX13TING ASSES3ED/APPRAISED UE � / OPOSED WORK S� - �� .�
SPJ.tINKLERED BUILDING? ��ES ❑ NO FI PRESSION SYSTEM PROPOSED%REQ �S ❑ NO
WATER SERVICE PROVIDER �cLAKEI�VEN-� ❑ HIGHLINE ❑ TACOMA ❑PRIVATE(WELL)
SEWER SERVICE PROVIDER t7�LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC�
-• •• -
AREA DE3CRIPTION ERISTING PROP03E TOTAL
S .FT. S S .FT.
BAS ENT
FIRST
SECOND
THIRD
FOURTH
ADDITTONAL FLOORS(DES BE) .
DECK(COVERED?)
GARAGE � CARPORT❑
�sx�o r so roriu.
NUMBER OF FLOORS
•''NEWHOMES ONLY'�* NUMBER OF BEDROOMS MATED SELLING PRICE $
Indicate numlier of each type of fucture to be installed o relocated as part of thcs 'ect. Do not include existing furtcires to��mdin.
MECfiAHICAL
Value of Mechanical Work $
AIR HANDLING UNITS EV ORATIVE COOLERS C1A3 LOd3 REFRIQ.SYSTEMS
gBQg F 3 HOOD3�co��� WOOD3TOVES
BOILER3 REPLACE INSERTS RANGES . MISC(Describe)
COMPRESSORS � FURNACES 4AS WATER H�ATERS
DUCTS (3AS PIPE OUTL�1'S
PLU1VffiING �
BAT TUBS�or7Lb/showercomeo► 3HOWERS WATER CL03ETS(ro�7ey MISC(Describe
DI3H�VASHERS 3INK3 DRINKINQ FOUNTAINS
(3A3 IPE OUTLE'fS 3UMPS RAINWATER 3Y3T
WASH G MACHIN URINAL3 H03E BIBBS
. LAV3 VACWM BREAKERS ELECTRIC WATER HEATERS
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I cert{fy under penalty oj perJury that ths ir{formatton furntshed by me is trus artd rnrrect to the 6est of iny knowledge,and further,tha!I
aun authortaed by the owner of the abow pnmtsss to perform the wor.k jor which the perneit a�ppiicatton ts made. I further agree to hoid
harmlus ths City of Federal Way as to any cfatm�includtng costs, expenses, and attorneys'fees irtcurred in the invsstigallon and deJsnse of
such ciain�,which rriay b ade 6y dny penon,inelud�ng the und rsigned,artd fiisii agatnsi the City of Federat Way,bnt only where auch ciatm
arisss out oj the reliance the etty,including its o and e ioyses,upon the accwacy oj the in j'orneatlon supptisd to the city as a part oJ
this appticatton. '
C �NAME/TITLE � DATE - '
( ignature) (T��l
RELATIONSHIP TO PROJECT 'Owner Agent o Contractor ❑Architect �Other
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