07-106843 •,+ . 11/
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Federal Way PERMIT
SF MF CO ME EL PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES
33325 8ru AVENUE SOUTH•PO BOX DEC 2 0 20pPLI CATI O N _ - -
253-835-2607•FAX 253-835-2609 - �__-
www.cituoffederalwautQrf„y OF FEDERAL WAY `— — -- �
The following is ret ( AelRJ,-an incomplete application will not be accepted. Please print legibly(in ink)or type.
!� 7 • PROPERTY INFORMATION
SITE ADDRESS J-( L}O 8 L ,+.
SUITE/UNIT#_
ASSESSOR'S TAX/PARCEL# `Z 1 S 4 (0 S - O C) -S Q LOT SIZE(sj)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description
• PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL ❑ ENGINEERING A FIRE PREVENTION SYSTEM
PROJECT DESC ON( wide de ' d description of work ' luded on this erm on1
PROJECT NAME(Name of Business or Owner Last Name) 1< ®A 117 '_V
• PEOPLE INFORMATION
PROPERTY NAMEiii.m/�YV\ v PRIMARY PHONE
OWNER MA IIIIII,,, ) -
ING ADDRESS CITY,STATE,ZIP E-MAILE-MAB.ADDRESS
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
fz.;1( 4g PAP/fe/jr--Ton .4cA C 04..E (2� )( z"3 -29`i3
MAILING ADDRESS DY,STATE,ZIP CELL PHONE
f t3e c c M -r- :&Gt / D �`-t f.C. ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
FXa 1-i -Z2(p7-'
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
t-C c P kr- i Z---f-,yff `c- ar-
t -- O '
APPLICANT COMPANY NAME APPLICANT NAMi OFFICE PHONE
(=e, ( Pax(kAi rr ii , fl ,. Cv a.. (2. )(D23 -29 T3
MAILING ADDRESS 11Y,STATE,ZIP /i c CELL PHONE
Pv [S'l;x `�`'r �� t�ieC 1{ 10 /� ( ) -
RELATIONSHIP TO PROJECT � F NUMBERR
❑ Architect ❑ Tenant 0 Agent r Other �11J/ CT�2 ) ii.4-I - 22(o`Z
PROJECTN j PRIMARY PHONE E-MAIL ADDRESS
CONTACT i�-C3,E, file,/ ' lC .e."-- (cZ(CO)g—ii - /92 5—
LENDER NAME Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( ) -
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
�EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ /1-(3-7 ,-
SPRINKLERED BUILDING? ❑ YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE o TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
S •
• PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED Sr TOTAL SP
**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$ (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLERS _ GAS PIPE OUTLETS WOODSTOVES
BBQS FANS GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(Commercial)
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS(or'nab/Shower Combo) LAVS(Bathroom sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(Totlet)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS
SIGNATURE
I cert(fy under penalty of perjury that I am the property owner or authorized agent of the property owner.I cert(fy 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.
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, but only
where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the information supplied to
the city as a part of this application. ^-7.
SIGNATURE: ✓' C7(..-1------> /� _ DATE / 2 r-Z-0—C� °I
Property Owner and/or Authorized Agent
❑NEW o ADDITION ❑ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? o YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? ❑YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#100-August 16,2007 Page 2 of 4 k\Handouts\Per it Application