08-103244CIV D
Federal Way PERMIT
COMMUNITY DEVELOPMENT SERVICES JUL 0 3 2 C 0� u
33325 3-8 AVENUE SOUTH • PO BOX 9718 ��, pv�� CATION
FEDERAL WAY, WA 98063 -9718
253- 835 -2607• FAX 2¢B.IQB OF FED L
www.ci[yofjedera.��c.�n i
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The following is required inQQ&n - an incomplete application will not be accepted. Please print legibly (in ink) or type.
SITE ADDRESS&
ASSESSOR'S TAX /PARCEL # _d Q? a / 40 ! �, - , /0!, & �^ LOT SIZE (S,i
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) �Rld 1, � 6/ 61✓
(Attach separate page for lengthy legal descrlptfoN
PROJECT • •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION XELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this ennit only)
' `
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PROJECT NAME (Name of Business or Owner Last Namel �dR /� �� �O/✓ �/�
PEOPLE •• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME,,)O Q/ / O�
PRIMARYHONE -
MAILI ADDRESS
X3156 .S• .��y �� Sao
CITY. STATE, ZIP
10d -elfl- ! 9"
E -MAIL ADDRESS
COMPANY NAME
/.' ��
/J^
APPLICANT aNAM,be.e�o•'✓/
I J4/ V
OFFICE PHONE a
�, /
�/ e& �'7 ' a�'"
OI/iCL 7 �7�
!ELL PHONE -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
9- 87- ocno`s5- ao --
EXPIRATION DATE
-a3/-� aeoR
FAX NUMB? ER
(as3) alg - a?3l d
CONTRACTOR'S REGISTRATION R
/% f /
: TIODAT
0 ,O �b%D
E -MAIL ADDRESS
AcobtRA6,va7Sm�jyS
COMPANY NAME
Sm, wS �RL `S S • /��✓ T
APPLICANT NAM /
,�.�aab�.4/•,/
OFFICE PHONE
(:„7S3) d�� - o7��cF'
MAILING ADDRESS /j
C �A� , ZIP �Q /
`ELL PHONE
RELATIONSHIP TO PROJECT�..yy
Xother t�0� 7�f{61�: "�R
FAX NUMBER
(0 ?53) a 9 -0?9&0
❑ Architect C1 Tenant ❑ Agent
NAME/ A D� PRIMARY PHONE E -MAIL ADDRESS
NAME
Per R 19.27.095:
Lender information is required (f project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED /APPRAISED VALUE $
PROPOSED USE
VALUE OF PROPOSED WORK $ -16 85.
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
---- 1
C;C4 -
9 •
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
WATER CLOSETS (Toilet)
SINKS
WASHING MACHINES
FIRST
p0
p O
95;1000
ZONING DESIGNATION
SECOND
CHANGE OF USE? ❑ YES
❑ NO
NEW ADDRESS REQUIRED?
THIRD
UP /SEPA /SU? ❑ YES
❑ NO
ADDITIONAL FLOORS (DESCRIBE)
❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
DECK (❑ COVERED OR ❑ UNCOVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
8X2ffrM
PROPOSED
TOTAL
TOTAL EMMO SF
TOTAL PROPOSED SF
TOTAL SF
"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 APPLICA970M
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS FANS GAS WATER HEATERS MISC (Describe)
BOILERS FIREPLACE INSERTS HOODS (commerdal)
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG. SYSTEMS
BATHTUBS )or Tab /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
❑ NO
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I cert(%y that to the best of my
knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with all applicable
City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the issuance of this permit
does not remove the owner's responsibility for compliance with local, state, or federal laws regulating construction or environmental laws.
Ifurther 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, but only
where such claim arises out of the reliance of the city, including its ofcers and employees, upon the accuracy of the information supplied to
the city as a part of this applicatio `.
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SIGNATURE: _ _ DATE
Owner and /or Authorized
❑ NEW ❑ ADDITION
❑ 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?
❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
❑ NO
Bulletin #100 - August 16, 2007
Page 2 of 4
k\Iiandouts\Permit Application