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07-104328 CITY OF RECEIVER 4a _ __EL (( 3 01 I Federal WayPERMIT COMMUNITY DEVELOPMENT SERVICES q SF MF CO ME EL PL DE FP 33325 ETH AVENUE SOUTH•PO PDX 97 G 0 3 FEDERAL 07 98063-9718 2A P P L I C A T I O N TD 253-835-267•FAX 253-835-2609 - www.crlyoffederalwau."CITY jO��F FEDERAL WAY The following is requci'€il Yn 73>ttLLYoh'-an incomplete application will not be accepted. Please print legibly(in ink)or type. O PROPERTY INFORMATION f SITE ADDRESS 3 `P� 3 P c-J i C_ ,(2 -5O �. SUITE/UNIT# a' 1 ASSESSOR'S TAX/PARCEL# 1 �, o d 5 D - 00 0 O LOT SIZE (s) 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 ❑ DEMOLITION 0 ELECTRICAL 0 ENGINEERING ®FIRE PREVENTION SYSTEM PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu) jkis 71":4_4(- so- v L 7;3 ba /Ln 6.-60 /41Y(5 u Li L,./ 4.-- ----- c-I-t eM/c..ra-c. ri I 7bcc A7 * o OctOU CA-- fttX- - 4)(7I°l/L-e-S,S14,NI ,:$'yJ PROJECT NAME(Name of Business or Owner Last Name) O n 1-1/ iv O.S ( G 649- //,r)- (• MI PEOPLE INFORMATION PROPERTY - NAME PRIMARY PHONE OWNER74MAAV/L ( ) - MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE ' ))t)i'.4/ -5',-1-) /;74&;; L�li)re ' �r .--o14-6,2- 7-/go 7(�SoW ( oi'. ) 4 �' -.6 osi MAILIN ADDRESS 3 ,'`' CITY,STATE,ZIP `���` CELL PHONE ( CITY DEI WWA B LICENSE NUMBER � -2))\-f .EXPIRATION DATE FAX NUMB ER Cr-1-5 h ? '1b S`^73 ( 'o6 (2-3 i-o 7 (y) .a 9V- // 3 COPY of card CONTRACTOR'S• REGISTRATION NUMBER EXPIRATION/ DATE E-MAIL ADDRESS with each app \tion �,// / U / r ]�/fir/ ,��� � ©L — O APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE ( ) MAILING ADDRESS CITY,STATE,ZIP CELL PHONE ( ) RELATIONSHIP TO PROJECT FAX.NUMBER 0 Architect 0 Tenant 0 Agent ❑ Other ( ) PROJECT NAME// PRIMARY PHONE E-MAIL ADDRESS CONTACT U.eASAy-- ( ) - LENDER NAME // Per RCW 19.27.095: Lender information is required if project value exceeds$5,000 MAILING ADDRESS CITY,STATE,ZIP PHONE ■ DETAILED BUILDING INFORMATION EXISTING USE PROPOSED USE EXISTING ASSESSED/APPRAISED UE$ VALUE OF PROPOSED WORK $� �I a jJ D " 0 0 SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO WATER SERVICE P DER ❑ LAKEHAVEN ❑ HIGHLINE 0 TACOMA 0 PRIVATE(WELL) SEWER SERVICE ROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC) AREA DESCRIPTION EXISTING PROPOSED TOTAL SQ.FT. SQ. FT. SQ. FT. 1 BASEMENT FIRST SECOND THIRD ADDITIONAL FLOORS(DESCRII . DECK(❑ COVERED OR 0 UNCOVERED?) ' GARAGE 0 CARPORT ❑ • 4 EXISTING PROPOSED TOTAL - TOTAL EXISTING Sr TOTAL PROPOSED Sr TOTAL Sr NUMBER OF FLOORS • **NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $ • . MI 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 i Value of Mechanical Work$• (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION) i i AIR HANDLING UNITS 'VAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES BBQS FANS GAS WATER HEATERS MISC(Describe) BOILERS FIREPLACE INSERTS HOODS(commeroio) COMPRESSORS FURNACES RANGES DUCTS GAS LOG SETS REFRIG.SYSTEMS i PLUMBING BATHTUBS or Tub/sh. . combo) LAVS)Bathroom Sinks) URINALS MISC(Describe) DISHWASHERS RAINWATER SYST VACUUM BREAKERS DRINKING FOUNTAINS SHOWERS WATER CLOSETS rroilet) ELECTRIC WATER HEATERS SINKS WASHING MACHINES HOSE BIBBS SUMPS • SIGNATURE _ 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. Pi NAME/TITLE �'ZC _" DATE '-;;.1-0 d s , igna ure) (Title) RELATIONSHIP TO R JECT 0 Owner 0 Agent W,Contractor 0 Architect 0 Other � °�FLdZ;I E ® L o NEW o ADDITION o ALTERATION o REPAIR ❑TENANT IMPROVEMENT BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO ZONING DESIGNATION CHANGE OF USE? a YES o NO NEW ADDRESS REQUIRED? o YES a NO UP/SEPA/SU? o YES ❑NO PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? o YES ❑NO Bulletin#100—April 2,2007 Page 2 of 4 k\Handouts\Permit Application