07-105368 ���� .
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• cwe�W�an,oBvscop,�m,sax►,ress PERMIT SF MF CO ME EL PL DE EN P
339?5 d�AV�M/S SOUiN•POBOX 9��P 2 6 20�P P LI �
� FBDBRAL WAY,WA 9d069•971A C AT I O N
959d9S?607�FAX 759-035��609
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`�ITV�F �zPF[aAL WAY __---
The jollowing ta raqu���o�a�qon=an incompiete appticallon u►tii not be accepted Please print.kgi6iy(in in or
! � �'
4 ' • ' • �
I BITE ADDRESS SUITE/UI�TI't'�
' ASSESSOR'S TAR/PARCEL� � �,�,� C�- �� � � ' LOT SIZE(s,�
�
� LFAAL DESCRIPTION(e.g.Acme Estates,Lot 1)
' �n�eo�r�.�e.�./�.w�wrwt�da..�,«wv
I ••• • • •
� TYPE OF PERMIT O BIIII.DINQ O PLUMBIN(� ❑ MECHANICAL
� ❑ DEM�LITION O ELECTRICAL � EN(�WEERIN(i�FIRE PREVENTION SYBTEM
PROJECT DESCRIPTION uide detailed des ' " n of work ' lu d on ermit nl '
.�i� e e �
c � 2 � M e . ,- .,
� �^— �o � H��� f� �
''� o Z� � e �
PROJECT•NAA3E(Name of Business or Owner Last Namel � 1,
• • • •
PROPERTY NnME
� C� 2��� �a�,n i L1.Li l ��t� {�r�o ( ZS pHySS
OWNER � _ / �
�D `� D��G� � I V C �� S�J CITY 3TA ZIP � E-MAIL ADDRES3
e� ev�� 1,..3
CONTRACTOR COMPAnr NA_n��s ,�ppuc� ,U,fE
� . /'Vl �lec�v ►�. �: � o�os rxoN
S� c 4Z , � _ -��2
�C�v �` �• S FC ��2 ,`�UCV iJ �� l�s C PHONB .
Sl0 -�798�
� � ITY OF FEDERAL WAY BUSINE33 WCENSF NUMHER EXPI TION DATE FAX NUMBER
� � � p_v _ - � L 23i-� ��fZS��y� - oo�
� NTRACTOR'8 R&GI ON NIIHH , !]� TION DATL ' ' E-MAIL ADDRBS9
� .�m� ^
� �L 2 -Z3 2C�8" f5��� �a�►�c c� �s�`'�
APPLICANT .��� �MPANY NAME �" �^� APPUCANI'NAME OFFICE PHONE r
,�..''� a�s G�oV ( ) . _
MAl11NU ADDRES3 CITY,3TATS,ZIP �CELL PHONE
RELATIONSHIP TO PRW ECT ' FAX NUMBER
0 Architect O Tenant o Agent o Other � j�f � � _ .
PROJECT NAME P MARYPHO E E-MAILADDRESS
CONTACT �l 2 - Q �
L$��g NAME Per RCW 19.9.7.093t
� ' Lendsr ti{formallon ta r�qutred(f proJect vaiue exeeeda�5,000 . �
MAILINO ADDRFSS ' C1TY,3TATE,ZIP ' . ' PHONB
� . ! � -
1
� � : � • • •
EXI$TW(3 xJSE P�20POSED USE '� ��� "`
EXI$TINQ�A$SES3ED/APPRAISED VALUE$ � VALUE OF PROP03ED WORK �t fC
BPRINKLERED BUII.DINQ? o YES �S NO FIRE$UPPRE38ION SYBTEM PROPOSED/REQUIRED? ❑YES �NO
.�
�I1�ATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HI(�HLINE ❑TACOMA � PRNATE(W�LL)
3EWER 3ERVICE Pi20VIDER ❑ LAKEHAVEN ❑ HIGFII.INE O PRIVATE(SEPTIC)
i . .. .
I , � AItEA DE� PTION .EXI3T1 PROPOSED TpTAi,
S :I+" 8 .FT. S .FT.
, BASEMENT � ^l .
. r' �J
FIRSf .
��� �
SECOND �
�c�X-� !
�� . 7� .
ADpITIONAL FIAORS(DESCRIBE) �
DECK(O COVERED OR O UNCOVERED?)
GARAGE � CARPORT ❑ � '.
NUMBER OF FLOORS n° �aorosso ror,u. ror.�s�raosr ron�c�arossau rorec�r �
�
•'NSW HOMES ONLY'• . NUMBER OF BEDROOMS ESTIMATED 3ELLIN(3 PRICE $
I
�
Indicate num6er of each type of fixture to be installed or relocated as part of fhis project. Do not inchtde existing fix(ttses to remain.
MECFIAIVIG9L I
Value of Mechanical Work$ (A COPY OF BID OR ESTIMATE MUS1'BE INCLUD,ED WITH APPLICATIONJ
A1R HANDL[Nd UWIT3 EVAPORATIVE COOLER3 (3A3 PIPE OUTLET3 WOOD3TOVES I
BBQ3 F�g t)AS WATER HEATER3 M13C(DeacrIbe)
BOILERS FIREPI.ACE INSER'fS HOODS(commard�p
COMPRE380R3 . FURNACES gp��}Eg
DUC7'9 C}A3 LOO 3ETS REFRIQ.SY3TEM3�
PLUMBINCi'
BATHTUBS(or�b/stw�arcombo� LAVS�B�thmoms4� URINAL.4 . MI3C(Describe�
DISHWA3HERS RAINWA"fER SYST VACUUM BREAKERS
DRINHINd FOUNTAIN3 3HOWERS WATER CIA$ETS�lo�ley
ELECTRIC WATER HEATERS 31NKS WASHIN(3 MACHINE3
H03E BIBBS SUMP3 �
� .
I cert(jg under penaity oj perJary ti�ct I am the prop�rly owner or authoriz�d agent oj the property ownen I csr;{/y that to t/u best oj my
knowiedge, the ir�ormatlon su6mitted in aupport o,/this psrmtt appiicaHon is true and correcG 1 cert�fy that I wlii compiy with ait applicabte
City of Alyderal Way rsgulations p�rtatninq to the work authorised by the tssuance o,/a perm;A J wtderstand that th�issuane�of this permtt I
do�a not remow th�owner's rsapoaslbiitty jor compiiancs with Iocal,atats,or fedsral iaws ngutating constructton or environmental laars. ��
I Jfrtrthsr agrss to hoid harmlear tht Ctty oj!'sderal Wgy aa to atny clatnt(lnciuding costa, 'expsnsei, and attorneyt'fets fncrvnd in the
inwaNgaHon and dt/enst oj such�Iai�, which may bs ntad�by any psrton, inciuding tht undeniqnet� and Jiisd aqalnst t/u ctty, 6ut oniy .
where sueh.clalm arisea out oj th�rsiianes oj ths clty, inciuding tts ofJicrra and empioysea,upon�the accuracy oj the I�formatlon suppiled to �
the city as a purt oj this appiica
ST(iNATURE: DATE / �� �/
perty Owner an /or Authorized Agent
o NEW o ADDITION o ALTERATION. o REPAIR a TENANT IMPROVEMENT
BUILDINQ 8HELL ONLY? a YES.o NO BA3IC PLAN? � o YFS o NO
ZONII�(�DE3IQNATION CHANaE OF IISE? o YES o NO �
HEW ADDRE83 REQUIRED4 o YES a NO • OP/BEPA/8UP o YES o NO �
PLATTED L�T? a YE3 a NO DEMO PERMIT REQUIRED? o YES o NO� �
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i Bulletin#100=August 16,2007 Page 2 of 4 . �k�Handouts�Permit Application
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