10-100367AECEIVE"-' PERMIT
Federal Way
CoMMUNnY>]L1VELo> s>" 2 " 201JAPPLICATICN
253-636-2007• FAX 253-936.2609
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SUITEMNIT # ZONING ASSESSOR'S TAX/PARCEL
NAME OF PROJECTf / _ f l ] �iCe-�
(Tenant or Homeowner Name) V JJ-,& ti (:� e k < Cc,( l p'� V"
❑ BUILDING ❑ PI,MING ❑ MECHANICAL
TYPE OF PERMIT ❑ DEMOLITION 1St ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION
7� t S f l w ,sL
PROJECT DESCRIPTION w C,,/
Detadled description of work to
be included on thls permit only
Q PEOPLE
PROPERTY OWNER NAIL �il�L.t o w0. I tatwO- Nice - vve3fu / LL&
WAILING ADDRESS. CrIY, STATE, ZIP
OWNER IS ALSO: ❑ CONTRACTOR 0 APPLICANT
NAPAZ
ONTRACTOR MAIIAVG ADDS, QTY. STATE, ZIP
".,06
WA STATECONTRACTORS UCENSE # >CIPDIA'IION DATE
wEs r"1CT0i� 130 r
NAME
APPLICANT ""'-e-- C', S C—
MAIIdNG ADDRESS, CITY, STATE, ZIP
PROJECT CONTACT NAME
Mie individual to receive and
respond W aU correspondence MAILING ADDRESS. CITY. STATE, ZIP
concerning this application)
ALTERNATE CONTACT NAME: P3UMARY PHONE
r I -
PROJECT FINANCING NAi�
Requiredforprgjects ulith
value of $5,000 or more MARINO ADDRESS. CITY. STATE, ZD'
(RCW 19.27.095)
PRDNARY PRONE
E-MAII.
PROJECT CONTACT
_ PRIBLWYP1ONE
Z53E� - W C,
FAX
FEDERAL WAY EUSINOW LICENSE #
PRISIARY PHONE
FAX
w�
PRDRARY PHONE
FAX
E-MAIL
OWNER -FINANCED
PRDNARY PHONE
I cerft under penalty ofperjury that I am the property owner or authorized agent of the property Owner. I terry that to the beet
of my knowledge, the if1formation submitted in support 4f this permit application is true and correct, I certt that I wilt comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance 4f a permit. I understand that the
Issuance of this permit does not remove the owners respansibility for compliance with ideal, state. or federal lawn regulating
construction or environmental laws.ineurrad
I further agree to hold harmless the City of Federal Way as to any claim {including costs. expenses. and attornays' jiaee
in the investigation and dq/ense 4f such claim), which may be made by any person. including the undersigned, and filed against the
city. but only where such claim arlsr out of the reliance of the city. including its qfficers and employees, upon the accuracy Rf the
G}formation supplied to the a rt 4f this application.
SIGNATURE:
DATE
PRINT NAME:
Bulletin #100 -January 1, 2010 Page 1 of 4 k:lHandouts\Peln it Application
Value_gTMie
indicate number a each.
AIR HANDLING UNITS
AIR CONDITIONER
_ BOILERS
_ COMPRESSORS
DUCTING
MECHANICAL FIXTURES
nkat Work $ to COPY OF BID OR ESTTMATE MUST B
qj f Urkere to be installed or relocated as part 9f his r4eeL Do not include
FANS GAS PIPE OUTLETS
FIREPLACE INSERTS HOODS (commemw)
FURNACES HOT WATER TANKS (aml
GAS LOG SETS REFRIGERATION SYST
GAS PIPING WOO DSI'OVES
PLUMBING FIXTURES
Ih r,- not include
Indicate number of each type of j7xture to be installed or relocated as a
M Pro
BATHTUBS (or Tub/shower combo)
LAVS (Hand Smke)
TOILETS _
_
DISHWASHERS
RAINWATER SYSTEMS
URINALS _
DRAINS
SHOWERS
VACUUM BREAKERS
!_ DRINKING FOUNTAINS
SINKS (Hitchen/Utamy)
WATER HEATERS W-tricl
HOSE BIBBS
SUMPS
WASHING MACHINES
GENERAL
INFORNIATIO ,
PROJEcr VALUATION
A Imo
3XISTRYGjP3BVIOUS USE
Utures to remain.
OTHER (Describe)
� j awes to remain.
WATER PIPING
OTHER (Describe)
TOTAL FIATUMN
WATER PURVEYOR SEWER PURVEYOR VALUE OF EXIaMG D0!ROVFMEM8
LOT SIZE (In Square Feet)
AREA DERCIUMON (in square
BASEMENT
FIRST FLOOR (or Mobile Home)
SECOND FLOOR
COV GR):D ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
Area Totals
EIISM0 FIRE iSL'9R SYSTEM? FROPOBED I' BUFF"MON BYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
RESIDENTIAL
VG PROPOSED TOTAL FOR OFFICE USE
axrarn�o
.
'NEW UONES OIVY,Y"
1 F;.S"I1MATED SF[.LIIVG PRICE $ 1 # OF BEDRIX=5
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Bulletin #100 -January 1, 2010 Page 2 of 4 k:\Handouts\Permit Application