02-103625CONSTAFION PERMIT APPLICATION
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APPLICATION NUMBER: - -
PPLICATION NUMBER: - -
* *The following is required information - Please print (in ink) or type **
Please note: Electrical, Fire Prevention Systems and Engineering permits may require a separate application.
PROPERTY INFORMATION
SITE ADDRESS: _, _ ASSESSOR'S TAX /PARCEL #— -t- -
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
- ''..■ 'PROJECT INFORMATION
TYPE OF PROJECT (This application): ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERINGXFIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description): (/G A1dAr-1,44 % • 6-"
PROPERTY OWNER:
CONTRACTOR:
APPLICANT:
■ PEOPLE INFORMATION T'
NAME: /'`vj1v,/ G DAYTIME PHONE:
MAILING ADDRESS (STREET AD CITY, STATE, ZIP):
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NAME:
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'DAYTIME PHONE:
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MAILING ADDRESS (STREET ADDRESS; CITY, STA , ZIP):
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MAILING AD R (STREET ADD ESS; CITY, STATE, ZI :
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EVENING PHONE:
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❑ ARCHITECT ❑ TENANT OTHER ( DESCRIBE):
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CITY OF FEDERAL WAY BUSINESS LIC SE NUMBER-.-
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FAX NUMBER:
CONTRACTOR'S REGISTRATION NUMBER:
EXPIRATION DATE:
(copy of card required)
NAME: •
DAYTIME PHONE:
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MAILING ADDRESS (STREET ADDRESS; CITY, STA , ZIP):
EVENING E:
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RELATIONSHIP TO PROJECT:
FAX NUMBER:
❑ ARCHITECT ❑ TENANT OTHER ( DESCRIBE):
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E -MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
EXISTING USE:
PROPOSED USE:
■ DETAILED BUILDING INFORMATION
EXISTING. BUILDING ASSESSED /APPRAISED VALUATION $
PROPOSED VALUATION FOR IMPROVEMENTS:
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED: ❑ YES ❑ NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
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* *NEW RESIDENTIAL CONSTRUCTION Y **
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE:
■ PR03ECT FLOOR AREAS
FLOOR
EXISTING S . FT.
PROPOSED S . FT.
TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
OTHER FLOORS (DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNITS) EVAPORATIVE COOLER(S) GAS LOG(S) REFRIG. SYSTEM(S)
BBQ(S) FAN(S) HOOD(S) WOODSTOVE(S)
BOILERS) FIREPLACE INSERTS) RANGE(S) MISC. ( )
COMPRESSOR(S) FURNACE(S)
DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: ❑ ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S) LAVATORY(S) URINAL(S) WATER HEATER(S)
DISHWASHERS) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINK(S) WATER CLOSET(S) MISC. ( )
INTERCEPTOR(S) SUMP(S)
DISCLAIMERISIGNATURE BLOCK _7
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 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 information supplied to the city as a part of this application.
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NAME /TITLE: � -- -- DATE: 2eo,
❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
COMMUNITY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063 -9718 • 253- 661 -4000 • FAX: 253 - 661 -4129
www.dtmffederalway_ =