07-101665�tr~� RECEIVED
Federal way PERMIT
COMMUNITY DEVELOPMENT SERVICES
13325 FEDERAL WAY, WA • PO BOX 971 PR 0 2 2ao7P P L I C AT I O N
FEDERAL WAY, WA 98063 -9718 r�
253- 835 -2607• FAX 253- 835 -2609
wiaiucittloffederal__ �au.EmCITYRR��O����'Fn(FEN(DE((RAL WAY
The following is reouip IYC�di�ifiS�o . an incomplete application will not be
SITE ADDRESS
ASSESSOR'S TAX /PARCEL # Z
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
/Attach separate pane for lengthy legal description)
PROJECT • •
SF MF CO ME EL PL DE EN FP
TD
ited. Please print legibly (in ink) or type.
SUITE /UNIT #
LOT SIZE (sj)
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
PROJECT NAME (Name of Business or Owner Last Name) 1 A 11 ) Uy Zf wl 1/0 1 V r---
PEOPLE •• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
LA ml �4 -
MAILING ADDRESS CITY, STATE, ZIP
COMPANY NAME
A PLICANT NAME
OFFICE PHONE
MAILING ADDRESS a' ` ���'"`�
60X-a SCr
TY, STATE, ZIP �j �7
�al
CELL P ONE
( -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
°! Z / 3( /01
FAX NUMBER
( ) -
t -/ 0 --000 0D--?-B L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAjJrING DRESS
� �
C , STATE ZIP
CELL PHONE
-
RELATIONSHIP TO PROJECT
FAX NUMBER
J
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe))f� /C—
( ) -
V ide 1
PRIMARY PHOU.
- ��/
ADDRESS 'A(
-5 ip
Per -RCW 19.27.09S: Lender information is
NAME
required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
EXISTING ASSESSED /APPRAISED VALUE $.
PROPOSED USE
VALUE OF PROPOSED WORK $.
3Oco
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)
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
o ALTERATION
❑ REPAIR ❑'TENANT IMPROVEMENT
FIRST
BASIC PLAN? ❑'YES
❑ NO
SECOND
CHANGE OF USE? ❑ YES
THIRD
NEW ADDRESS REQUIRED? o YES ❑ NO
UP /SEPA /SU? ❑ YES
FOURTH
PLATTED LOT? o YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
HXISTINO
PROPOSED
TOTAL
TOTAL EX1 -11111'
TOTAL PROPOSED. SP
TOTAI.SF
* *NEW HOMES ONLY ** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECUAAYCAL
Value of Mechanical Work $
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS for Tub/ Shove :Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Bathroom sinks)
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
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 b�q made by any person, including the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the relianc f the city, including its officers and employees, upon the accuracy of the information supplied to the city as apart of
this application. ��� /,' `�/# �J / /�f
NAME /TITLE�� 01&( / DATE 3611 /
M./ " I (Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner [Agent El Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
❑ NEW ❑ ADDITION
o ALTERATION
❑ REPAIR ❑'TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑ YES ❑ NO
BASIC PLAN? ❑'YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE? ❑ YES
❑ NO
NEW ADDRESS REQUIRED? o YES ❑ NO
UP /SEPA /SU? ❑ YES
❑ NO
PLATTED LOT? o YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
❑ NO
Bulletin #100 — January 7, 2005 Page 2 of 4 k \HandoutsV'ermit Application