06-100783 0110 S
Fed,A.er la Way
RECEIVE D L k: - ( oo + gs
PERMIT
COMMUNITYDEVELOPMENTSERV(CE$"�1� 1 7 2006 SF MF CO ME EL PL DE EN FP
33325 D R LWA .Wfft1•63971 97 86 r.J ,LI CATI ON
FEDERAL WAY.WA 98063-9718
1 8 To
253-835-2607•PAX 253-835-2609 L / /
www.cituoffederalwau.cvn ''r` (,)(" FEDER
gtLILDING DEPT,
The ollowin• is r-.vire ormation-an incom•lete a••lication will not be acc•.ted. Please .rint le!ibi- (in ink)or ••.
• PROPERTY
ROPERTY INFORMATION
SITE ADDRESS 3ra o / A-i
SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# 9 2 C9 '430- 02_ I0
LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estate's,Lot 1)
(Attach separate page for lengthy legal descrtptbN
• PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 1IRE PREVENTION SYSTEM
PROJECT DESC ION(Provide detailed description of work included on this permit onlu) ,
r cru --TP.A-0E1-ce S (,4J6w r i )
PROJECT NAME(Name of Business or Owner Last Name) I u21C..k , 1 CSS r�,[vA,Ps1�- (02012eizry+ u�iik )
U PEOPLE INFORMATION
PROPERTY NAME CORIMARY PHONE
OWNER VI/l N YC 113S 7 or Civ-)1-D'4- ( ) -
MAILING ADDRESS CITY,STATE,ZIP
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
AM- SECui ITy 5ER vies i2c' Bax (q25 ) 460 -52Ltg
MAILING
ADDRESS
/n-e �/u/ Y/�// CITY,STATE.ZIP CELL PHONE
024 F FEDERAL
DA! V�•EFIL/�(jy/IJ I05 eD LL (A/ON f8o(/ ()53)3� - - 114L
CITY DATE FAX NUMBER
1 L-i a-1 a 5 5 k 7- - B L / / ( )
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
4 0 %S t 5.27 0 Z 0 5 Cf / ?5 /07
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
59s14 E rk 67vne4C?'d2 ( ) -
MAILING ADDRESS CITY,STATE.ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant ❑Agent 0 Other(Describe) ( ) -
I
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS 1
f 11S (owT,Z�Tz�2 ( ) - I
LENDER Per RCW.19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY.STATE.ZIP PHONE
( ) -
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE yy�� 1
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 4 100.OV
SPRINKLERED BUILDING? ❑ YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
• •
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 0
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 offixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Volt e of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commercial) 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(toilet) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES 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 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 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. /�
NAME/TITLE Q DATE 2-1'4-v
(Signature) `z (Title)
y
RELATIONSHIP TO PROJECT 0 Owner 0 Agent r Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
o NEW o ADDITION a ALTERATION o REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑YES ❑NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? ❑YES o NO
Bulletin#100-January 1,2006 Page 2 of 4 k\Handouts\Permit Application