08-100100 ,I
RECEIVE* •
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Federal Way � 0 7 D� �
JAN PERMIT SF MF CO ME EL PL DE EN n
COMMUNITY DEVELOPMENT SERVICES �-/
33325 D AVENUE SOUTH•PO BOX 9718 PPLI CATION O N
FEDERAL WAY,WA 98°,1;69,10F FEDERf1L TD / � �,
253-8352807•FAX 2531- 1 1 L..�e•�'�
ivwwciWo((ederttlwaqrUILDING DE 1 ••' ���UUU
The following is required information-an incomplete application will not be accepted. Please print legibly(in ink)or type.
• PROPERTY INFORMATION
SITE ADDRESS ,, 2-097 ?)Zvnd -AO e..._ '- SUITE/UNIT# '
ASSESSOR'S TAX/PARCEL# Z I 5 4 S C) - 0 0 1 0 LOT SIZE(4) 17 1 3-C,blT
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 0 ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only) ...i
-VN SVC‘--1‘ in Fir-e____ Pf Z.rJ.-Ylkt c r\ j ednt -v t., ir. 4 •
4.
I;of-M TV
PROJECT NAME(Name of Business or Owner Last Name) 1& Y\ QvVIe..(tCA✓1 i
NI PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER V0'r,' �✓1 AiM IC (1_ CC,' ( ) -
MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Parc- -A d0- 3 -1 (2_6 ) 6.,L0 - 59 to
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
I I 2--g--t IJ CA -Ic Pt' $7NWA i t 17 O t 1 ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE UMBER EXPIRATION DATE FAX NUMBER
( )
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
Se-ryl t-- 0L-5 C-0 V\-WGc..DC ( ) -
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect a Tenant a Agent a Other ( )
PROJECTNAMk PRIMARY PHONE E-MAIL ADDRESS
�
CONTACT 1l '_. (Q52)) te2.D- £ Ci, t Q
LENDER NAME Per RCW 19.27.095:
Lender Information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAIS`E/ Z
D VALUE$ VALUE OF PROPOSED WORK $ '1C?0 D
SPRINKLERED BUILDING? 1 YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
•
• PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR ❑UNCOVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
**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)commerdap
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS or Tub/Shower Combo) LAVS)Bathroom Sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(roue.)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS
SIGNATURE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I certify 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._
SIGNATURE: � :a�.
���
� DATE /1 /O
Prope Owner and/or Authorized Agent
FOR OFFICE USE ONLY
o NEW o ADDITION o ALTERATION n REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? n YES n NO BASIC PLAN? n YES n NO
ZONING DESIGNATION CHANGE OF USE? o YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#100—January 1,2008 Page 2 of 4 k\Handouts\Permit Application