06-103817 iVoS" - toy 3O8 -10
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Federal Wa AUG 2006 PERMIT T
COMMUN IYDEVELOPMENT SERVICES SF MF CO ME EL PL DE N FP
33325 8",AVENUE,WA 9•
4SS 9718 �P LI C AT I 0 N
FEDERAL WAY,WA 98063-�it�y Q�FEDE .
253-835.4607•FAX 253435-ldAg ' y -_. .
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The oilowin• is re•wired information-an inco •lete a••lication will not be acce;� d. Please •rint legibly in in or j• .
�c+, Al,—lPROPERTY INFORMATION
SITE ADDRESS -3C-L14 O 1 (4 tl I S. AL / SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# j 0 Z ( 0 4 - /q 0 0 (O LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attack separate Mela mar!Val demv+ptian)
1 PROJECT INFORMATION
TYPE OF PERMIT ❑B LDING ❑ PLUMBING ❑ MECHANICAL
• r - u OLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provicfe detailed
i %e s oa o k included on this ermit o l 0,
r'i4 �iar� 'Z�'�lh t. c ubf " C -°�uw
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PROJECT NAME(Name of Business or Owner Last Name)
CkittS--r4.--
PEOPLE INFORMATION
PROPERTY
n ( ` � P NEL Q�./�
OWNER 1�i aS UL t(/, �n'`/�`t� L[/! �i'��. 4 � sesb1 -(O 1
ILTN A DR J C 3T TE;ZIP
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE -
O
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
• / / (
B L
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each applieatloa( EXPIRATION DATE
/ /
APPLICANT COMPAgNYY NAME APPLICANT NAME OFFICE PHONE
l J (-4-) -C l_ (
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
(
RELATIONSHIP TO PROJECT FAX NUMBER
❑Architect ❑Tenant o Agent ❑ Other(Describe) ( ). -
CONTACT NAME 6,..tc.94, PRIMARYTPHONE _ E-MAIL ADDRESS
LENDER NAME ��
MAILING ADDRESS CITY,STATE,ZIP PHONE
(
'DETAILED BUILDING INFORMATION
EXISTING USE L.W • 1 4 (A{ e V PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK ($ •
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)
i
111 411
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FLOORS susrao � �
**NEW HOMES ONLY'* NUMBER OF BEDROOMS E r TED SELLING PRICE $
TIXTURES
Indicate number of each type of fixture to be installed. relocated as part o is project. Do not include existing frxtcres to remain.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS VAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(Comma WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS • FURNACES GAS WATER HEATE'.
DUCTS GAS PIPE OUTLETS
PLUMBING •
BATHTUBS(orTub/ rCombo) SHOWERS WATER CLOSETS Iroeaq MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE 0 ETS SUMPS RAINWATER SYST
WASHING ACHINES URINALS HOSE BIBBS
. LAVS(Bathroom Sinks) VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
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 authorised 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 mad ,_ any person,including the undersigned,and filed against the City of Federal Way,but only where such claim
arises out of the licence oft ci ,including its officers and employees,upon the accuracy of the information supplied to the city as a part of
this application
' ' ' -
NAME/TITLE _ ` N i�1Y I4'�1�4 `SATE r4OTI.0-1°C) c)
(Signs (Title)
RELATIONSHIP TO PROJECT o Owner 0 Agent Contractor 0 Architect I]Other
! .i .s: z ar ?Falsiz'"� i'',� � tig °� :-a� J'°�. �r�ib
/,,,,h4',01 .,u ;ti, ,,' '5 n,1° .1s.'. 0 sd� ai nl r , 4�•C \4 rs '',,h'll'"1:C,1 ^''.'.,t, .,�j J;" .^%;e ,1.`:'
111111P/ill in(1n m—lanuary 1 20(16 Pace 2 of 4 k\Handouts\Pemut Annlication
DEPARTME OF COMMUNITY DEVELOPMENT SERVICES
A 1 33325 8th Avenue South
CITY OF �w:0".. 9 P Box 9718
Federal Way WA 98063-9718
FederalWay.1 www.cityoffederalway.com
DEMOLITION PERMIT REQUIREMENTS
A demolition permit is required to remove any structure or structures on a subject property. Check with the City's Planning
Division to see if the proposal exceeds thresholds that trigger an environmental review.An environmental review and
submittal of an environmental checklist may be required,which will extend the time period before a demolition permit can
be issued.
O Prior to submitting a demolition permit,the following items(as applicable)must be signed by the respective
agency(see attached Demolition Permit Contact List).
NOTE TO APPLICANT: Utilities shall be disconnected and services performed,if applicable,prior to issuance of the demolition permit.All applicable
items below are to be signed and dated by the respective agency representatives.
1.ASBESTOS ABATEMENT 6. ELECTRICITY
(Copy of approval form and asbestos survey from Puget Sound Clean Air (Electridty to shut off and mater removed)
Agency provided) N Vac �S (kc uj
/l id• /t 1-.1 (Puget Sound Energy)
(City of Federal Way Building Offidal)
2.GAS SUPPLY 7. FUEL STORAGE TANKS
(Gas to be shut off,meter removed and final bill paid) (A•• e or below grade fuel tanks, have been pu •-d or removed
under - Department permit prior to any disc.ntle/excavation)
(Puget Sound Energy)
(Federal Way Are Di'. ct#39)
3.SEPTIC S '1 EM 8.WATER-Public .urce eck applicable box)
(Tank to be remove• or tank to be d .ned and filled) ❑Meter to be removed an. • utility bill paid
❑Meter to remain and be pr. ed
(King Cow Environmental Services) (Water - ..ier)
4.SANITARY SE R (Che applicable box) 9.WATE' Private Well(Check app' able box)
❑Sewer line cape:. at property lin- ❑Privat- ell filled and capped
❑Existing sewe me to remain and •- sed by proposed new structure ❑Priv, e well to be used for other purposes
(Sewer Distri (King County Environmental Services)
5.G •BAGE
(All ousehold garbage disposed off and final bill •-id)
(RST Disposal/Federal Way Disposal) RECEIVED
❑ Completed Construction Permit Application form AUG 0 2 2006
❑ Provide the following fees: 1.Demolition Permit Fee $65.50 CITY OF FEDERAL WAY
2.Automation Fee 5.00 BUILDING DEPT.
3.WA State Surcharge 4.50
4. Cash Bond Deposit 500.00 (Refundable upon Completed Final Inspection)
$575.00
Bulletin#122—January 1,2006 Page 1 of 1 k:\Handouts\Demolition Permit Requirements
Agency Case No. PUGt T SOUND CLEAN AIR
AGENCY RECEj ' d
200600678 110 Union Street,S E Seattle,WA 98101- O CIV DAUG 0 2 2
006. www.pscleanair.org
Agency Use Only CI( Air A' etncy NOTICE OF IN C11511-4) 21G�PUu AIR AGE ut.intio
.F EA 'ly
A.Proiect Tyne: 1. ❑ Friable Asbestos Removal 2. ❑ Friable AsbRelifireElianDeigijon 3. Et Demolition Only
B. _? r/
Property Owner: C r 1 S K( Al Phone: s J"- cp ,/- /js,:).
Mailing Address: ...3_-S `7 eS 1/"`i 17"q City: Fe-CCP-fed 1416�/ State frt./11 Zip:gi
C. Asbestos PLEASE PRINT CLEARLY.THIS WILL BE YOUR RETURN MAILING LABEL. /
Contractor: I1 SSi'rt ct Of,cLid./ Owner/CEO:
// Contractor
Mailing Address: 2 7 Oa t/ '4 s '7-ri2., Phone: 2,.3 --7)- 7/7r Job No.:
City: Tat CriIMCt State: ,it4 i Zip: L7' (( L(to- Fax: 8-cs 79 C!- i-/6010
D. Site
Address: -3 syyr f/( 74-t..t€ S City: i4.v'C-1 /de o/ Zip:
Site
Manager: Local Phone:
E. ld"Asbestos Survey or No.of Date of Asbestos / / Was Friable Asbestos Identified? ❑Yes o
❑ Mat'l Presumed Structures: / Survey: /�+/ Was Nonfriable Asbestos Identified? ❑Yes (NO
AHERA Building i ��, Certification#: _ -0.4 Attach a copy of the survey when friable asbestos
Inspector: at..vt vA o vl I t 0eckvt y Exp.Date: ---o �2.V0.6 has not been identied
An AHERA Survey is required before all demolition projects
F. Demolition Start 1 No.of 1. LJ Training Fire(List Fire Dept.)
Information: Date: ID -04— 0 f Structures: 1. 2. ❑ Ordered Demolition(attach copy of Order)
Demolition Insert demolition contractor's ailing address on back. Will nonfriable asbestos be left in place during demo? ❑ Yes ErNo
Contractor: 1. '`/ If yes,list type and qty. Note disposal requirements in Step 6(on back).
G. Friable Asbestos Work Days: M T W Th•F Sa Su
Project Information: Start Date: Completion Date: Hours:
Will all friable asbestos ❑ Yes
Total Qty.to be Removed: Linear Ft. Square Ft. materials be removed? ❑ No
LJ BoilerWumace Insulation ❑Duct Insulation U Pipe Insulation '1 C ';.roofing ❑ Paints CI Plaster U Textured Coatings
CI Cement Board ❑ Cement Pipe ❑Friable Flooring ❑Fria e -•• t' lal Other:
IA 1 uttiv41..'4'„ix, 4 7
H. Asbestos/Demolition Project Categories: :909 `7 Notification Period Project Demolition
1. Single-Family Residence(owner-occupied):
'3-77 Fee Surcharge
RCPT. O. °l 3�
A.,❑_, bestos Removal Project Only „ A.Prior Notice A. $25
B. U Demolition Project(with or without asbestos removal project) B. 10 Days* B. $50
*(Asbestos removal can begin upon notification;demolition must wait 10 days)
Note:If the single family residence is owned by one family who has been or will be using the residence as their domicile, the above boxes
IA or 1B may be checked. If this is not an owner-occupied residence,one of the categories listed below must be used instead. A single
famil re idence does not include rental property, multi family units, or any mixed-use building.
2. 11 Other Demolitions(with no Asbestos removal or Nonfriable Asbestos 10 Days ..1rn!,
only or less than 10 linear feet and/or 48 square feet of friable Asbestos)
Friable Asbestos Projects(other than Single Family Residence): Asbestos Demo
3. ❑ L10-259 linear feet and/or>_48- 159 square feet of asbestos Prior Notice 10 Days $100 $100
4. ❑ 260-999 linear feet and/or 160-4,999 square feet of asbestos 10 Days $200 $100
5. ❑ >1,000 linear feet and/or>5,000 square feet of asbestos 10 Days $600 $100
6. ❑ Emergency Asbestos Project or Emergency Demolition Project Prior Notice Fee
(Single-Family Residences are exempt from emergency fee;however,property owners must provide a written emergency request)
I. I certify that the information cont4cd in this no !cation&supplemental data is,to the best of my knowledge,accurate&complete. Age i ' se Only
et1�'4L ‘
61"6.1 ilk Xil°'.' B-0. -°6 J ��.o✓
Signature Representing Date Reviewed By • '
Puget Sound Clean Air Agency Form No.: 66-160(Revised 2/05)TS ,-3,/0 a` O 0 7--e3. -e-A'L