05-101904 c���,L ` - l v / a
CiTr Of
Federal W a y R i`JP E R M I T
COMMUNITY DEVELOPMENT SERVICES _ S O ME EL PL DE EN FP
33325 8ra AVENUE SOUTH•PO BOX 9718 APR 2 2
FEDERAL WAY FAX 98063 9718 �A p L I C AT I O N ° ._._:- - �
253-835-2607•FAX 153-835-2609
www.tityoftederalway.com
CITY OF FEDERAL WAY
The ollowin. is re.uired' ' ��P inco .fete a..lication will not be acce.ted. Please .rint le.ibl (in in or .-.
• PROPERTY INFORMATION
SITE ADDRESS .- « _
�'� Z'�Zir- V l t-D l d, SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# �� � - `��� ,S C/U LOT SIZE(sj) (�v(
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal desoipnon)
• PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlg)
+■.-Ak-0112 --sL%.5'r c t•I b\ _ 7-tt- C a►v,_ 0 5C11-r1 try ■Q-p 0
& c_L `-/ C-D IU-Po 6 Crl atovJ So la- Gt_.Pc5 5 A-- ^ -6/ - acts,
PROJECT NAME(Name of Business or Owner Last Name) C'c Vd . /e_
• PEOPLE INFORMATION
PROPERTY NAME PRIMARY
i PHONE
OWNER 3 P w -F�Pe-T,E S (7-. 3)HO Q
S LS -
MAILING ADDRESS
CITY,STATE,ZIP
')-5-t>) 1 5u) 5 3 Co`- R- -- uDiary Lae,- Fa a)-3
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
U-ilAD CL `�'(crC s D i Lk.VJ� (Y53) `j a-� ( so 3
MAILI ADDRESS CITY,STATE,ZIP 980,3 CELL PHONE
6 t 3,b2�LS) (? ) �0- S q LS
CITY OF FEDERAL ABU SLICENSE EXPIRATION DATE NUMBER
3-1 0 - . L 9 Q c.- B L ' / (as3) 9->-s- Is 2
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
( ) -
MAILING ADDRESS CITY,STATE,ZIP - CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect ❑Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT E PRIMARY PHONE E-MAIL ADDRESS
Lt ti lC (sob) s -°o J i (3 �,t...} Ms13. Ltstiv(
LENDER erR6W9 27,09ec5.Leid er lnform aion is NAME
? r udif pro t£aatue exc¢d $S 000 e
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE I l)1-T-% - 1-Pt%&L uf. C V 1 .) PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ t1 6.6 6-
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)
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ. FT. SQ. FT. SQ. FT.
BASEMENT
FIRST
roSO0 ( O o r"
SECOND b DO O 0606
THIRD
FOURTH .
ADDITIONAL FLOORS(DESCRIBE)
•
DECK(COVERED?)
GARAGE ❑ CARPORT❑
EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF.
NUMBER OF FLOORS
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
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 $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commrrm,a1) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or Tub/Shower Combo) SHOWERS WATER CLOSETS
(rode) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Smks) 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 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 out of th eliance of the ci._r� •ing its officers and employe upon the accuracy of the information supplied to the city as a part of
this applicatio ��
NAME/TITLE , f <-5 I 4(. /°
DATE
(Si; re (Title)
RELATIONSHIP TO PROJ ❑ Owner ❑ Agentntractor ❑ Architect ❑ Other
a " n ADDITION n ALTERATION a REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES ❑NO BASIC PLAN? ❑YES - ,T. e
ZONING DESIGNATION CHANGE OF USE?- ❑YES _ O
NEW ADDRESS REQUIRED? o YES ❑NO UP/SEPA/SU? - ❑YES a NO
PLATTED LOT? o YES ❑NO DEMO PERMIT,
REQUIRED?
Bulletin#100—January 7,2005 Page 2 of 4 k\Handouts\Permit Application