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Permit # i� L-Pq3 170 b
CITY OF FEDERAL WAY
BUILDING PERMIT APPLICATION
— Please Print —
BOX 1 TENANT NAME: PAv&j1X mop-7'6A&C 2e3
OWNER 11t] nib I�Vkne P,4t'-fAf 1C'77.S .moo. SITE LOCATION t5v
OWNER'S ADDRESS1 CITY ;� PHON l -7.v- 1"
DESCRIBE JOB 7 j4"C- iP1t -5
THE PROPERTY IS OWNED BY: SINGLEIMARRIED PARTNERSHIP be - CORPORATION
BOX 2 CONTRACTOR'S NAME ��7r ���a et'! CONTRACTOR'S REG.
Card MUST be presented
CONTRACTOR'S ADDRESS WOP7 A,'T 4V CITY � � �%�_, PHONE 2-30'?*
EXPIRATION DATE
—OR—
I HAVE READ CHAPTER 18.27.010 RELATING TO DEFINITIONS OF GENERAL CONTRACTORS AND SPECIALTY CONTRACTORS AND
CHAPTER 18.27.110 WHICH PROHIBITS ISSUING PERMITS WITHOUT PROOF OF REGISTRATION.
BOX 3 CONTACT PERSON rab IV e22 A`,tl PHONE k k 7-30
BOX 4 SEWER DISTRICT _ WATER DISTRICT
BOX 5 ESTIMATED PROJECT COST 'I" /CX> _ EXISTING BUILDING VALUATION
BOX 6 PROPERTY TAX ACCOUNT NUMBER 6,32-01 1,0 014,0- 41, Q�. Ci- P/ze) -'91 e vZ --a
LEGAL DESCRIPTION 1 60 I r 17 1j1gZ�Vg
(If necessary, please submit a separate page with the legal description.) 1
cc,
K.C. Plat Recording #•�.
BOX 7 BUILDING SQUARE FOOTAGE: (Existing/Proposed) 1ST
FLOOR-1 2ND
FLOOR
3RD FLOOR / BASEMENT- �
ECK 1
GARAGE�i
BOX 8 ( ) SINGLE FAMILY (
) NEW CONSTRUCTION
( ) MULTIFAMILY (NO. OF UNITS = ) (
) EXISTING STRUCTURE
COMMERCIAL/INDUSTRIAL _ TOTAL AREA OF PROPERTY �t2�
SQ FT
BOX 9 PLUMBING FIXTURES (including rough -ins)
MECHANICAL APPLIANCES — BASIC FEE $
N0. WATERCLOSETS >�IV F GAS PIPING, FEET
BATHTUBS-' NO.
—FURNACE, ELEC. GAS
$
SHOWERS
�� ��)^��
GAS HOT WATER HEATER
$
—LAVATORIES
CONVERSION BURNER
$
BOILER, SIZE BTU
$
,SINKS
DISHWASHERS tTyp; �Gi_ta°,,:nv
AIR HANDLIN }NITS
$
ELECTRIC HOT WATER HEATW1`
HEAT PU SIZE
$
LAUNDRY WASHER OUTLET
UNIT TERS
$
URINALS
_ AIR OLING UNITS, SIZE
$
DRINKING FOUNTAINS
SUMPS, SPRINKLER VACUUM BREAKERS
DRAINS
OTHER
TOTAL FIXTURES
MERCIAL HOOD
ER
TOTAL MECHANICAL FEE
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 PERMIT APPLICATION IS
MADE. I FURTHER AGREE TO SAVE HARMLESS THE CITY OF FEDERAL WAY AS TO ANY CLAIM (INCLUDING COSTS, EXPENSES, AND ATTORNEYS'
FEES INCURRED IN INVESTIGATION AND DEFENSE OF SUCH CLAIM), 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.
OWNER/AGENT _ �---;-r_ +� raAT� _/I-
ANP-009 3/90
OFFICE USE ONLY (PLEASE DO NOT WRITE BELOW THIS LINE)
ZONE SETBACKS: FRONT_
PLANNING DEPARTMENT APPROVAL
REMARKS:
SEPA: EXEMPT_ NOT EXEMPT
FIRE DEPARTMENT APPROVAL
REMARKS:
SIDE. _ REAR_ HEIGHT LIMIT
PUBLIC WORKS DEPARTMENT APPROVAL _
REMARKS:
DATE_
TYPE OF JOB: NEW RESIDENCE RES. ADD/ALT NEW INDUSTRIAL IND. ADD/ALT
NEW COMMERCIAL COMM. ADD/ALT NEW MULTIFAMILY (UNITS )
MULTIFAMILY ADD/ALT TENANT IMP. OTHER
OCCUPANCY TYPE OF CONSTRUCTION _ _ STORES
BUILDING SQ. FT. @
BUILDING SQ. FT. @ _
BUILDING SO. FT. @ _
BUILDING SQ. FT. @
BUILDING SO. FT. @ _
BUILDING SQ. FT. @
TOTAL SQ. FT. TOTAL VALUATION
BUILDING DEPARTMENT REMARKS:
RECEIVED
ASSIGNED ADDRESS:
PARTIAL PLAN CHECK FEE RECEIVED
Amount Date Receipt #
BUILDING DEPARTMENT APPROVAL
DATE
PERMIT FEE
PLAN CHECK FEE
PLUMBING FEE
MECHANICAL FEE
TOTAL BLDG. FEES
PART P/C FEE
SEPA REVIEW
S.B.C.C. FEE
OTHER FEES
AMOUNT DUE
ACCEPTED FOR FILING