03-105316CONSTRUCT10i PERMIT APPLICATION
CITY OF •
PPHCATION NUMBEI.: - L Q -
Federal Way
1JECEIV EV PPLICATION NUMBER: _ _ _ _ _ _ -
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PPLICATIOINUMBER:
* "The followi- HiGec�il QQ dwotmation - Please print (in ink) or type**
Please note: Electrical, Fire P %WRVAytgRAO "gineering permits may require a separate application.
SITE ADDRESS: (t,29 Sy 3S0 ASSESSOR'S TAX /PARCEL #: -
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
■ PRO]ECT INFORMATION
TYPE OF PROJECT (This application): o BUILDING ❑ PLUMBING o MECHANICAL ❑ DEMOLITION
o ELECTRICAL o ENGINEERING04IRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description):
PROJECT NAME:
PROPERTY OWNER: NAME: f� ; DAYTIME PHONE,
l c7 R-au le- LA /Cf- �j M W�. c e �.i C L-tu 2 C 1+v- (ZS 3) ?a SC- 1 r 2.
MAILING ADDRESS (STREET ADDRESS; CITY, STATE, ZIP):
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CONTRACTOR: NAME: DAYTIME PHONE:
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I MAILING ADDRESS (STREET ADDRESS; CLTY, STATE. ZIP): I. EVENING PHONE'
I k l0 Z %, G(P-A 06% L--f— 21-z. (ZS3 )G-0 6 - /'L / 7
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: FAX NUMBER:
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CONTRACTOR'S REGISTRATION NUMBER: / L EXPIRATION DATE::
(ropy of card required) E_ AA L- ci A F ` g o d re- _ ; tZ / 3
APPLICANT• I NAME: DAYTIME PHONE:
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MAILING ADDRESS (STREET ADDRESS; CITY, STATE, ZIP): A EVENIING PHONE:
L / /V Z ( CG f-I M ex- 9-rl iCp vl(fs?L�iG� i (2ENsz-$ 3
' RELATIONSHIP TO PROJECT: i FAX NUMBER:
O ARCHITECT ❑ TENANT �9 HER ( DESCRIBE):
i
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: 11 PROPERTY OWNER o APPLICANT CONTRACTOR
--EDEUILED 13UILDING INFORMATION
EXISTING USE: EXISTING BUILDING ASSESSED/ APPRAISED VALUATION ; 0
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: �L
SPRINKLERED BUILDING? ❑ YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED: ❑ YES ❑ NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER: o LAKEHAVEN ❑ HIGHLINE o PRIVATE (SEPTIC)
.:.A
* *NEW RESIDENTIAL CONSTRUCTION O *
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE:
FLOOR
EXISTING S . FT.
PROPOSED S . FT.
TOTAL
BASEMENT
FIRST
SECOND
THIRD
;
FOURTH
OTHER FLOORS (DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
FIXTURES
Indicate number of each type of fixture
MECHANICAL Value of Mechanical Work: $
AIR HANDLING UNIT(S) 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 HEATERS)
DISHWASHERS) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINKS) WATER CLOSET(S) MM.( )
INTERCEPTORS) SUMP(S)
3TSC1LA1MER 1STGNAT11RE RLC
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 ou of the reliance of the city, Including its officers and employees, upon the accuracy
of the information supplied to the d a art this application.
SST, Z-U NAME /TITLE:
❑ PROPERTY OWNER ❑ APPLICANT CONTRACTOR
COMMUNITY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063 -9718 • 253-6661 -4000 • FAX: 253-6661 -4129
www.cVOffcderalway.com