07-100436RECEIV _ o Q Y_
Sk CITY OF
Federal way - PERMIT
COMMUNITYDEVELOPMENTSERVI JAN 2 6 2007 SF MF O ME EL PL DE EN FP
3332E D AVENUE SOUTH • PO BOX 9718 , p L I C AT I O N TD
FEDERAL WAY, FAX 98063 -9718
as3- a3s- aco7•FAxasa- a3s -�ybTY OF FED ER
wujw.dtuorrederalwau.com BUILDING DEPT.
The following is required information -an incomplete application will not be accepted. Please print legibly (in ink) or type:
SITE ADDRESS LN) Qhn SUITE /UNIT H _
ASSESSOR'S TAX /PARCEL # Z? ? d - g v �� LOT IZE
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) e. 11 tl 1 T 54,. .
(Attach separate page for lengthy legal description) rva -
TYPE OF PERMIT - S\BUILDING ❑ PLUMBING ❑ MECHANICAL
.0 DEMOLITION O ELECTRICAL ❑ ENGINEERING I PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only) ��JJ
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY.
OWNER
CONTRACTOR
COPY of card raquired
with each appllaatlon
APPLICANT
PROJECT
CONTACT
LENDER
a
NA
PRIMARY PHONE
MAILING ADDRESS
C "/,ATE, ZIP
EMAIL ADDRESS
COMPANY NAME
APPLICANT NAME
` PL[CANT NAME
OFFICE PHONE
CITY, STATE, ZIP
CELL PHONE ,
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent b Other
FAX NUMBER
( —
M II:ING ADDR \\
SEWER SERVICE PROVIDER
CITY, STATE, ZIP
CELL( PHONE
CITY OF FEDERAL WAY SINESS CEN NU BE
EXPIRATION DATE
FAX NUMBER
016 L�
CONTRACTOR'S REGISTRATION NUMBE
EXPIRATION ATE
MAIILA,DDD.R I l
L
`E�
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
(
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE ,
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent b Other
FAX NUMBER
( —
�p EE \ \ PRIMARY PHONE E -MAIL AD RESS
NA
Per RCW 19.27.095:
Lender lgormation is required if project value exceeds $5,000
/m7NOADDRESS
CITY, STATE, ZIP
PHONE
WATER SERVICE PROVIDER
❑ LAKEHAVEN
SEWER SERVICE PROVIDER
EXISTINGYL SE I V
aT� (�
EXISTING AS SED /APPRAISED
VALUE $
SPRINKLERED BUILDING?
❑ YES ❑ NO
WATER SERVICE PROVIDER
❑ LAKEHAVEN
SEWER SERVICE PROVIDER
❑ LAKEHAVEN .
PROPOSED USE CA"Cg. b-,YV_ .
-VALUE OF PROPOSED WORK $
FIRE.SUPPRESSION SYSTEM PROPOSED /REQUIRED? O-YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
SQ. FT.
PROPOSED
S . FT.
......... ......................
TOTAL
SQ. FT. 1
BASEMENT
GAS WATER HEATERS MISC (Describe),
BOILERS
FIREPLACE INSERTS
FIRST
COMPRESSORS
FURNACES
RANGES
SECOND
GAS LOG SETS
REFRIG. SYSTEMS
THIRD
CHANGE OF USE?
❑ YES
a NO
ADDITIONAL FLOORS (DESCRIBE)
YES o NO
UP /SEPA /SU?
DECK (❑ COVERED OR ❑ UNCOVERED ?)
o NO
PLATTED LOT? n YES o NO
GARAGE ❑ CARPORT
❑ YES
_ :�\V1
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL EXISTING Sr
TOTAL PROPOSED St'
rOTAL Sr
" *NEW HOMES ONLY *" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work
(A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
BBQS
FANS
GAS WATER HEATERS MISC (Describe),
BOILERS
FIREPLACE INSERTS
HOODS (commercial)
COMPRESSORS
FURNACES
RANGES
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
PLUMBING
T_ BATHTUBS (Tub/Shower Combo)
DISHWASHERS'
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
LAVS (Bathroom Sinks)
URINALS MISC (Describe)
RAINWATER SYST
VACUUM BREAKERS
SHOWERS
WATER CLOSETS (Toilet)
SINKS
WASHING MACHINES
SUMPS
BUILDING SHELL ONLY? o YES o NO
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 the permit application is made. I further agree to hold
harmless the City of Federal Wag 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 information supplied to the city as a part of
this application.
NAME /TITLE
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor
,\ DATE
(Title)
❑ Architect ❑ Othet
Bulletin #100 —January 1, 2006 Page 2 of 4 k \Handouts\Permit Application
o NEW o ADDITION
❑ ALTERATION
o REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO
BASIC PLAN?
❑ YES
Cl NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
a NO
NEW ADDRESS REQUIRED ?. a
YES o NO
UP /SEPA /SU?
❑ YES
o NO
PLATTED LOT? n YES o NO
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
Bulletin #100 —January 1, 2006 Page 2 of 4 k \Handouts\Permit Application