08-100201 g - a 3__ _ 0o of
COMMUNITY DEVELOPMENT SERVICES PEE R M IT SF MF CO ME EL PL DE 701
33925 dri AVBNUB SOUTH•PO BOX 9718 J�l p _ 1
53435-L W7Y,FAX 93 435.260 /i Y "�;,;p p L I C AT O N � �4,
?53 R95 9607•FAX?3495.4609
tnrow.dtunAF.der/due3'i7pM� — / 5 p
OF The following is required r lets application will not be accepted. Please print legibly(in inky or type.
�
j / II PROPERTY INFORMATION
SITE ADDRESS_/ 1'I. COW W'O►\S 112 -B c(-Is/014 c1,$ SUITE/UNIT•
ASSESSOR'S T A X/P A R C E L# & v)- y D _ Q Q / O LOT SIZE(sJ
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach•Ararat*Me/Or knOthIl kV,a gepemy
• PROJECT INFORMATION
TYPE OF PERMIT ❑BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING IRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work inducted on this permit only) •
H r:1 , v4eAses
' ' Co Wl�1�,�S PROJECT NAME(Name of Business or Owner Lost Name) `L _`,. • A_ �✓ `'A _
II PEOPLE INFORMATION „
PROPERTY NAME /
PRIMARY PHONE
OWNER /� -
MAILING ADDRESS ° l� CITY,STATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANY E �� A rrry OFFICE PHONE
�(.00"I/e_eS't Vtt,..c 991.04- � (926' //Y
MAILING DRESS ^ l� STATE, CELL PHONE
157�� 6 /' w� R ' (2.06 )3G 7 S'fY3-
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
r c.5 l b�6$cj Oa/3L- • /2/ S' 6255 70- ?.3 it/J 4 ;
CONTRACTOR'S REGISTRATION NUMBER. EXPI RATION DATE E-MAIL ADDRESS
PV G 5 a 3 KF $76/°8
APPLICANT MPANY NAME A N /OFFICE PHONE
'
MAILING/�DDRESS/�I�C V�i � / "av l cps) "7 -LM�
/ 5N/G'33 p Z1' 4(4. (/v ZIP tzdx i CELL PHONE `
►�k t •(�06)3 6 9 SKy
RELATIONSHIP TO PROJECT L FAX NUMBER
o Architect a Tenant a Agent ❑ Other CA)M1 ' TZr' ( ) _
PROJECT N;xm"- PRIMARY PHONE E-MAIL ADDRESS stt CONTACT ) b c� _
LENDER NAME Per R .095:
nder I formation is required if project value exceeds$5,000
MAILING ADDRESS (YTY,STATE,ZlP PHONB
IE )
U DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK .2-2-5,.o.
SPRINKLERED BUILDING? 0 YES O NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? l] ONO
WATER SERVICE:PROVIDER a LAKEHAVEN a HIGHLINE ❑TACOMA CI PRIVATE(WELL)
SEWER SERVICE PROVIDER Cl LAKEHAVEN a HIGHLINE a PRIVATE(SEPTIC)
AREA DESCRIPTION EXISTING PROPOSED TOTAL
BASEMENT SQ.FT. SQ.FT. SQ.FT.
FIRST
•
SECOND
•
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR ❑UNCOVERED?)
GARAGE ❑ CARPORT ❑
•
maroon OF FLOORS msraa maroon TOTAL TOTAL SShcmlesr TOTAL PROrossosr TOTALS?
•
"NEW HOMES ONLY" NUMBER OF BEDROOMS -ESTIMATED SELLING PRICE $
• FIXTURES
Indicate number of each type of fudure to be insta -d or relocated as part o this project. Do not include existing fixtures to remain.
MECHANICAL .
•
Value of Mechanical Work$ (A %•• OF BID OR ESTIMATE MUST:• I CLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLERS OAS PIPE 0 S WOODSTOVES
BBQS FANS GAS WATER HEATERS MISC(Describe)
• BOILERS FIREPLACE INSERTS HOODS tc"mmndq
COMPRESSORS
•
FURNACES RANGES
DUCTS. • GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS or rub',,. LAVS(Bathroom AMMO URINALS MISC(Describe)
• DISHWASHERS RAINWATER SYST VACUUM BREAKERS
•
DRINKING FOU NS SHOWERS WATER CLOSETS gam
ELECTRIC WA R HEATERS SINKS WASHING MACHINES
•
HOSE BIBBS SUMPS
•
•
SIGNATURE
I certify under penalty of perjury that I am the property owner or authorised agent q f the property owner.I eerti fil that to the best q f my
knowledge,the information submitted in support of this permit application is true and correct.I corgi&that I will comply with all applicable
City of Federal Waif regulations pertaining to the work authorised 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.
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 9f such claims, which may be made by any person, including the undersigned, and filed against the city,but only
where such claim arise out of the re ante of the city,including its officers and employees,upon the accuracy of the information supplied to
. the city as a part of re • ,pllcatio
SIGNATURE: - 1144/4. % DATE ///q06
Pro.!rrOwner and/or Authorized Agent
•
a NEW a ADDITION . a ALTERATION a REPAIR o•TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES a NO BASIC PLAN? a.YES a NO
ZONING DESIGNATION CHANGE OF USE? a YES a NO
NEW ADDRESS REQUIRED? a YES a NO UP/SEPA/SU?
o YES a NO
PLATTED LOT? a YES a NO DEMO PERMIT REQUIRED? a YES a NO
•
•
Bulletin#100—January 1,2008 Page 2 of 4 k\Handouts\Permit Application