07-102210CITY OF Tea.+►
Federal Way RECEIVEr PERMIT
F MF CO ME EL PL DE EN
COMMUNITY DEVELOPMENT .SERVICES
3332FEDERAL VENUS .APPLi CATI O N `°
53-8WAY, WA 98463.9719 P R 2 A 2n07
P53.535•?fiU7• FAX 753.835-T6 '# U
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The following�l !WAV an incomplete application will not be accepted. Please print legibly (in ink) or type.
SITE ADDRESS _ .�4q a PAC [�w� �' _ SUITE/UNIT # .
ASSESSOR'S TAX/PARCEL # -S ! — S� LOT SIZE (sj)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for lengthy legal description)
PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING �FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work' luded on this permit onl
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
COPY of card required
with each application
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME
Per RCW 19.27.095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP PHONE
( )
EXISTING ASSESSED/APPII
SPRINKLERED BUILDING?
WATER SERVICE PR
SEWER SERVICE P VIDI
❑ ❑ NO
O LAKEHA
❑ LAKEHAVEN
PROPOSED USE
VALUE OF PROPOSED WORK $ SL�C� •�
FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
NAME PRIMARY PHONE
V, S /4,j V�/ ( ) -
MAILING ADDRESS CITY, STATE, ZIP E-MAIL ADDRESS
COMPANY NAME
�--►2C- /r,
APPLICANT NAME
Ki( 5 euil n
OFFICE PHONE
(J-53 ) 3`75
- 3c71
MAILING ADDRESS
CITY, ST
�
ZIP
JAI 9 912-4
CELL PHONE
993
- Gl
o i 3`i5t�
L,
,7S3
CITY OF FEDERAL BUSINESS LICENSE NUMBER
EEXXPIRATION DATE
FAX NU�MBEpR�
rWAAY
C) , ( V \ 9 l -1 — 0 V
I\
C� - -3 ( ` V -7
(,; SS3 ) O 75
JLt7`�
CONTRACTOR.'$ REGISTRATION NUMBER
EXPIRATION DATE
E-MAIL ADDRESS
fo D
r f(7,Ao-
(h'nC�ra
COMPANY NAME
C-N " r. (',^ , :,J
APPLICANT NAME
A A e,,r-
OFFICE PHONE
033) 8-75 - 3e f 6
MAILING ADDRESS
CITY, $TAT 1P
CELL PHONE
S3)
C093
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other
FAX NUMBER
NAME PRIMARY PHONE E-MAIL ADDRESS
co/-,(� F�� a-s, 993 o'I„Pr c CQrnC IS�
e�
AREA DESCRIPTION EXISTING
BASEMENT
SQ. FT.,'
PROPOSED I TOTAL
SQ. FT. SO. FT.
FIRST
.SECOND
THIRD
ADDITIONAL FLOORS (DESCRIBE)
DECii (i) COVERED OR ❑ UNCO' J
GARAGE 0 CARPORT
NUMBER OF FLOORS 1 wuaa�rtu I PROPOSED i T07M�� 7D A �--at
"NEW HOMES ONLY+* NUMBER OF BEDROOMS ESTIMATED
MAL rporasae sr 7oraf.
PMCE $
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS '
PLUMBING
BATHTUBS (or Tub/Sho *rCo _)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
(A COPY OF B OR ESTIMATE MUST Sfi INCLUDEp W1M APPLICATION)
RAIN TER SYST VAC T BREAKERS
SH ERS WATER CLOSETS jroaet)
S WASHING'MACHINES
SUMPS
EVAPORATIVE COO RSr GAS
MI
MIS
PIPE OUTLETS WOODSTOVES
FANS
_ GAS WATER•HEATERS
I cert((ry under penalty of perjury that the Ir e"natten furnished by me is true and correct to the best of my kavwiedge, and further, that !
am authorized by the owner of,the above premises to perform the Werk for which the permit application Is made, I further agree to hold
harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred In the tnvestigation and defense of
slrch 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 effacers and employees, upon the accuracy of the WOrmation supplied to the city as a part of
this application.
NAME/TITLE'
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent
o NEW ❑ ADDITION o ALTERATION
BUILDING SHELL ONLYo YES ONO
ZONING DESIGNATION
NEW ADDRESS REQUIRED? o YES o NO
PLATTED LOT? o YES ❑ NO
(T111c)
❑ Architect ❑
❑ REPAIR ❑ TENANT IMPROVEMENT
BASIC PLAN?
o YES
n NO
CHANGE OF .USE?
a. YES
o NO
UP/SEPA/SU?
o YES
❑ NO
DEMO PERMIT REQUIRED?
o YES
❑ NO
Bulletin 4100—April 2, 2007 . - Page 2 of 4 k\Handouts\Permit Application