04-10153505 "/ 001 13:29 FAX 5 561 1 ,. CITY FEDERALWAY 002
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CONSTRUCTION PERMIT APPLICATION
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PPL_ICK110N NUMBER_ —
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F PLICA N NUMBER:
'The Following is required information — Please print (in ink) or type'*
Please note: Electrical, Fire Prevention SysLems and Engineering permits may require a separate application.
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SITE ADDRESS: I • �+— ASSESSOR'S TAX/PARCEL_--
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LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
TYPE OF PROJECT (This application): 17 BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
d1 ELECTRICAL ❑ ENGINEERING IRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description):
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PROJECT NAME: (:_
PROPERTY OWNER: NAME paY-Mh RIiC?NI;
MAaaa:, ADUkCSS(, RECT nODe•E�S: Dili, _ i nTc. ZIP): -
CONTRACTOR` NAME: DAl-'I MF PHONL%
v �.CvENiMG PHON14D-430t)
(I f • jai f r}ETL vrlNy t> CzaSE Nue+EER fA);
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('(JNl'kACTOR'S ItEI`.L r"uR..i rON MLIMDER: EXPIRAI :ON DATE:
APPLICANT: NAME: Dme
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MAILING ADDRESS r_qi, _E-T ADDRESS: cm. ,-,rAVE 7.IP): EVENING PB aDNE:
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REATioNS�sII' ,a o �fisaj ECT rNUMBEE
❑ ARCHITECT ❑ TENANT orHER (DSCRIi): ( ) a
E.M:ABL ADDRESS; ,
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ❑ APPLICANT CONTRACTOR I
EXISTING USE: _ EXISTING BUILDING ASSESSED/APPRAISED VALUATION S -
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS:
SPRINKLERED BUILDING? ❑ YES Ll NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: YES ❑ NO
WATER SERVICE PROVIDER.: ❑ LAKEHAVEN 0 HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER.: ❑ LAKEHAVEN l7.1 I{IGHLINE ❑ PrdIVATL- (SEPTIC)^
0,''9/21 .13:29 FAX 253661412E--
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',-r4EW RESIDENTIAL CONSTRUCTION ONLY"`
NUMBER OF BEDROOMS: ESTINSATED SELLING PRICE: �n; �e
FLOOREEEXISTING FT. PROPOSED . FT. TOTAL
BASEMENt 1
FIRST
SECOND /
THIRD
FOURTH /
OTHER FLOORS (DESCRIBE)
DECK_
GARAGE
HOW MANY LOO
TOTAL:
Indicate number of each type of fixture
MECHANICAL
;DISHWASHERCS)
HANDLING UN (S) EVAPORATIVE COOLER(S) GAS LOG(S) REFRIG. SYSTEM(S)
Q(S) FAN(s) HOOD(s) WOODSTOVE(5)
LERS) FIREPLACE INSERT(5) RANGE(S) MLSC_ r
MPl s (s FURNACE(s)
(S GAS PIPE OUTLET(s) HEAT SOURCE: j=J ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S) LAVATORY(S) URINAL(S) WATER HEATER(S)
RAIN WATER SYS. VACUUM BREAKER(s) O ELECTRIC ❑ GAS
INKING FOUNTAINS) SHOWER(S) wash MACHINE OUTLET
GAS PIPE OUTLET(S) SINK(S) WATER CLOSET(S) MISG ( )
INTERCEPTORS) -SUMP(S)
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 ofthe above premises to perform the work 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
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 info rmatio.tt
upplie, the city as a part of this application.
NAME/TITLE: DATE: it
❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
FOR OFFICE USE ONLY:
❑ NE'911i' ❑ ADDITION O ALTERATION ❑ REPAIR ❑ TENANT IMPROVEMENT
CENSUS CODE: LOB E::
ZONING DESIGNATION: -BUILDING SHELL ONLY? ❑ YES El No " .
COMP PLAN DESIGNATION BASIC PLAN? ❑ YES ® No
SECTION TOWNSHIP RANGE NEW ADDRESS RE UIRED3 ❑ YES ❑ NO
E L - YES NO CHANGE OF USE- ❑ YES 0 NO
CITY MERALWAY