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19,
Permit Xz/� f z -z z 5�6
,u 3 0 1992 CITY OF FEDERAL WAY
�,„_ BUILI]ING-PERMIT APPLICATION
,arm rJ 4.1.'x" a, a -
rra... 4r'i+ ��., s — Please Print —
BOX 1 TENANT NAME:
OWNER Vlca ci f M i r r Z m u Iu SITE LOCATION
OWNER'S ADDRESS 3561 £1 o 5 1A J. CITY Fe--cl&I a PHONE 0
DESCRIBE JOB" " e. r t
THE PROPERTY tt OWNED Y: SINGL MARRIED PARTNERSHIP CORPORATION
BOX 2 CONTRACTOR'S NAME
CONTRACTOR'S ADDRESS
EXPIRATION DATE
CITY
—OR—
CONTRACTOR'S REG. #
Card MUST be presented
PHONE
I HAVE READ CHAPTER 18.27.010 RELATING TO DEFINITIONS OF GENERAL CONTRACTORS AND SPECIALTY CONTRACTORS AND
CHAPTER 18.27.110 WHIgH PROHIBITS ISSUING I ERMITS WITHOUT PROOF OF REGISTRATION.
BOX 3 CONTACT PERSON
BOX 4 SEWER DISTRICT,(_ m!�WeZ,d ._ WATER DISTRICT Y4 / �
BOX 5 ESTIMATED PROJECT COST DaqO'. 00 EXISTING BUILDING VALUATION YL _
BOX 6 PROPERTY TAX ACCOUNT NUM
LEGAL DESCRIPTION
(If necessary, please submit a separate page with the legal description.)
K.C. Plat Recording #
BOX 7 BUILDING SQUARE FOOTAGE: (Existing/Proposed) 1ST
3RD FLOOR / BASEMENT /=
S
FLOOR�6�J see 2NDF OR – /
DECK___J_ GARAGE__ _ � _576-
BOX 8 .(>.d SINGLE FAMILY ( ) NEW CONSTRUCTION
( ) MULTIFAMILY (NO. OF UNITS = ) ( ) EXISTING STRUCTURE
( ) COMMERCIALJINDUSTRIAL TOTAL AREA OF PROPERTY SQ FT
BOX 9
LUMBING FIXT RES (including rough -ins)
MECHANICAL APPLIANCES — BASIC FEE $ -- ----
0. ATERCLOSETS
GAS PIPING, FEET
. $-. -- -
ATHTUBS
N FURNACE,ELEC. GAS--
$
SHOWERS
GAS HOT WATER HEATER-$
LAVATORIES
CONVERSION BURNER -
- $
SINKS
BOILER, SIZE BTU
$
DISHWASHERS
IR HANDLING UNITS
$
ELECTRIC HOT WATER HEATER
HEAT PUMPS, SIZE
$ . -
;.� ! LAUNDRY WASHER OUTLET
UNIT HEATERS
$
-
URINALS
IR COOLING UNITS, SIZE
$ --
DRINKING FOUNTAINS
COMMERCIAL HOOD
$
SUMPS, SPRINKLER VACUUM BREAKERS
OTHER ��-
$
DRAINS
_
$
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 ASTO 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: DATE: ._ �
ANP -DOB 3/90
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Date By
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CDO183