05-101132 05/29/2001 13:29 FAX 2536614129 CITY FEDERALWAY • lii1002
• IREi /ED
CONSTRUCTION. PERMIT APPLICATIO
in t- MAR 1 1 2005 APPLICA-110N NUMBER: Os- �
1 o _ o-:.Y-I
• d�� CITY OF FEDERAL WAY A - - - - - - -
F'PLIt;ATION NUMBER: - z _
BUILDING DEPT. APPLICATION NUMBER: - •
"The following is required information-Ptease print(in ink)or types*
Please note: Electrical,Fire Prevention Systems and Engineering permits may require a separate application.
_-:: -..• --_ -- . -.:•-I :.-.-..:. -:.--f-:.:--: •- :-:..;- = MI PROPERTY INFORMATION .: '. _ .' -
u
SITE ADDRESS: ZA 1 t ASSESSOR'S TAX/PARCEL =J: -
— _ -
LEGAL DESCRIPTION
NNSOF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY): '
RC-Jir
_ E _ -■ PROJECT INFORMATION .-. ., °"-
TYPE OF PROJECT(This application): C1 BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
1] ELECTRICAL ❑ ENGINEERINGFIRE PREVENTION SYSTEM
X PROJECT DESCRIPTION (Provide detailed description):
• PROJECT NAME: `A*"f1 1 i ''c`46 c - _.
. .. . , . : ■ PEOPLE INFORMATION .• . . -. .. . . • - .
PROPERTY OWNER: NAME .D,„ NW e m5 DArnf MPHONE ` 1 -I
DO 4 ! 3 9z
MArU NO ADORC;S(STREET AODIZES`:(fl'r,STATE,ZIP):
CONTRACTOR: NAME: — Dn mME(HON-:
5N)Xsira'SOS 9.1'611 GAJ
MAII IND ADDRESS(STREET ADORU:5S;CM'.STATE,Z(P): CvENING PHONE:,
- 5 r-t(? -+ l i s . 5 1 3k (Z.a .) `316 3 t)
0117 Of FEDERALV1A BUUSLNESSlUCENSE NUMBER: FAX NUMBEIL:
.59- - 1 0 (Q D teZ - Db_ (20(a ) * 113J i
CcNIRACTOR'S REGISTRATION NIIMOER:
11'.—N S_G^ EXPIR.Al N GATE:
% (`� / 05
(copy of cad reODUCi1)
> -
APPLICANT: NAME: (OAb •)ME FHON4:C 0--. . 300
MAILING AODR SIRCETADDRESS;CITY,STATE_,ZIP): EVENING PHONE:
Ill Oji_ Al* 5 SC "T 9°61 3' ( ) -
RELATIONSHIP 10 PROJECT: FAX NUMBER:
❑ ARCHITECT CITENANT F OTHER(DESCRIBE):5Utt,t oE,t-- ( ) - _ -
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: 0 PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
■ DETAILED BUILDING INFORMATION - . -:
• EXISTING USE: _ EXISTING BUILDING ASSESSED/APPRAISED VALUATION s
PROPOSED USE: . PROPOSED VALUATION FOR IMPROVEMENTS: $ 5 ` D.,VD ,>
IN SPRINKLERED BUILDING? ❑ 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 LAKE1IAVEN C1 1IIGHLINE 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 0 CARPORT 0
EXISTING PROPOSED TOTAL TOTAL F OSTDP6 8F ,�TOTAL PROPOSED SF 'TOTAL SF
NUMBER OF FLOORS z
**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.
MECHAIVICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commrc al) 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(Batkuoomsinks( 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,inclu.ing its officers and employees,upon the accuracy of the information supplied to the city ass
s a part of
this application. /'
NAME/TITLE .i*.
�j DATE /,W'
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner o Agent ❑ Contractor ❑Architect 0 Other
a. .
�® = UDITIOI -4pXL ERATION ❑REPAIR PL- p4 TENANTfiIP;120YEMENT '�
UILDING�FIELL-ONLY? AYES O 4 ,,BASIC�PLAN? # ' o YES, b NO .
�r t (•G�ESIGNATION���F '',:,----.---W., ' • 1C
_ � ,� �. � � RANGE OF USES ��� �.� ❑YES.!..:'•.;
�� 0��
a IJ KESS REQUIRED?t . �PEST O�* .; UPJSEPA/SU? a E - gi i ,a YES - 'i!IO g,
'''i);''').11,7: YP§,, _ O a.,,"'r 7,7772�,` DEMO PERMIT EQIIIItED t3'YES O
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Bulletin#100—January 7,2005 k\Handouts\Permit Application
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