04-10491910mr of
Federal Way P E RM TT -� -
COMMUNITY DEVELOPMENT SERVICES
33530 FIRST WO 8 D 0
FEDERAL WAY, WA 9886 3-9798 XPPLICATION
SF MF CO ME EL PL DE E FP
25wcuygf• JFedX er2a5lw-4729
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CITY OF FEDERAL WAY
BUILDING DEPT.
The following is required information — an incomplete application will not be
accei2ted. Please Print le ibl (in ink) or e.
PROPE,RTY INFORMATION
SITE ADDRESS 3456 S r,u-t h 3 449 " . WAY `�' t�-tT'r-- l ? o . FgJb t "`•(w OA 'I 6M
1
SUITE/UNIT # 13b
ASSESSOR'S TAX /PARCEL # k � � U - Q LOT SIZE (sf)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attack
separate page for lengthy legal description)
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION
SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
n Y, jFi
Owner PROJECT NAME (Name Of Business or
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
NAME PRIMARY PHONE
MAILINGADDRESS CITY, TE, ZIP
Tt
COMPANY NAME
yA,,[P/PLICR)NAME (�,9
OFFU FIICE PHONE
f ^ Q
MAILING ADDRESS
-0 10
q5_
CITY, STATE, ZIP
CELL PHONE
(W130 -621P
5
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBE a EXPIRATION D T
t °f- l D 5 945-B
FAX NUMBER
( )�til
t�bo
-0
L
}�
CONTRACT'OR'S REGISTRATION NUMBER (co y of d required with each application)
S P L �
EXPIRATION DATE
/ o -1 / 0 ('V
1 +-1 l.-
01
COMPANY NAME
APPLICANT NAME
OFFICE PHONE _ 14 f D7..�3
S I 1a->< hi vw�.AS-�
� () . 2zu -✓
(`L�i.) ?� f - t�Fl, gr
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
C15 20 10 }t- A j e S . t v
`1e aX l �2 W 1 i 'IS Icy $
( ) 73 0 - 10 3,
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant [Agent ❑ Other (Describe)
FAX NUMBER
(2�0o ,L1 f - IS-Do
NAME PRIMARY PHONE E -MAIL ADDRESS
LENDER Per ;itCW s9.z7. o95: Lender ig6rmation is NAME
required }fprojeet value exceeds $5,goo
MAILING ADDRESS CITY, STATE, ZIP
'WATER SERVICE PROVIDER ❑ LARAVEN ❑ HIGHLINE
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE
0
• TACOMA ❑ PRIVATE (WELL)
• PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . Fr.
BASEMENT
o YES o NO
BASIC PLAN?
IRST �10 ��
ZONING DESIGNATION
SECOND
o YES o NO
NEW ADDRESS REQUIRED?
o YES a NO
THIRD
UP /SEPA /SL- ❑ YES
a NO
PLATTED LOT?
FOURTH
DEMO PERMIT REQUIRED?
a YES a NO
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL EXISTING SF:
TOTAL PROPOSED SF
TOTALSF
* *NEW HOMES ONLY ** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
type of fixture to be installed or relocated as part of this project. Do not
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or Tub /shower combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (Commercial)
RANGES
GAS WATER HEATERS
WATER CLOSETS (Toilet) _
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
to
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
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 apart of this application.
NAME /TITLE tt L t'1.i 1 -IOU �� Y> �k � l7t}u SM ���Q DATE f � ' � ' 0 `
(Signature) (Ti )
RELATIONSHIP TO PROJECT ❑ Owner 9 Agent [Contractor ❑ Architect ❑ Other
o NEW ❑ ADDITION
❑ ALTERATION
❑ REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY?
o YES o NO
BASIC PLAN?
o YES o NO
ZONING DESIGNATION
CHANGE OF USE?
o YES o NO
NEW ADDRESS REQUIRED?
o YES a NO
UP /SEPA /SL- ❑ YES
a NO
PLATTED LOT?
a YES o NO
DEMO PERMIT REQUIRED?
a YES a NO
4P
Bulletin #100 — March 30, 2004 Page 2 of 4 k \Handouts — Revised\Permit Application