07-103999 •Q ^ `r
111. RECE� V
Federal Way JUL x g 2007 PERMIT 7)�? -`
COMMUNITY DEVELOPMENT SERVICES SF MF CO ME EL PL DE EN
3332F8DEAVENUE WAY, ATH•6O91g*0- FEDERA APPLICATION
FEDERAL FAX
98463+ � / /
253-835-2607•FAX 2S3-835-2�J LDING DEE'i
www.cit4offederalwau.com
The following is required information-an incomplete application will not be accepted. Please print legibly(in ink)or type.
GG •a �PRROPERTY INFORMATION
SITE ADDRESS_ Q 1 . ' A A" JQL) 4 SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# "' 2. C' 5 0 4 - 0 0 c 0 LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) `t J CAM P J, o PFt c_ 4kR 01\1.5
(Attach separate page for lengthy legal description)
• PROJECT INFORMATION
TYPE OF PERMIT ❑ 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 onlg)
AD') /►RE T E FIRE SPRk r,LE 5 a E w
T r SPACE
PROJECT NAME(Name of Business or Owner Last Name) Pic_ M En " paii-t \ CARE. C' ULJ(.Q
• PEOPLE INFORMATION
PROPERTY NAME /� PRIMARY PHONE
OWNER 'VIi2Gli-Irl-t -'k��0 CL1J(C. ( ) -
MAILING ADDRESS .. CITY,STATE,ZIP E-MAIL ADDRESS
(tOO 7' - At .,e c *06(
(
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
ikE S` ST S waS irk STO-4-AR (23)S. 3 - 12.4C3
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
2i *.t ►TAcb i2L� � AC1f=t( :��� 47 ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
coPt 041
A �\d/ 9,. )81 — O000D 14
-Co -B
CONTRACTOR'S REGISTRATION NUMBER 2/Ai /0;7
EXPIRATION DATE
(z 3)735
-al (3
E-MAIL ADDRESS
with each application rj/ S!K/`140B‘ `o/121o7
AT COMPANY StfSTebl5
w i 5 i APP OFFICE PHONE
APPLICANT
2 33 -42.48
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
,2� P .'TE RD i,► . t PACtFtC w A 9eCeiT( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect ❑Tenant XAgent 0 Other (2 ).735 -0 113
PROJECT NAMEC _ PRIMARY PHONE E-MAIL ADDRESS
CONTACT � (� �.1.1t A 7'\ _i 0.0k1a l (267) B-3.-- -‘242)
LENDER ®��/ NAME Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
1�tE X1 /� U DETAILED BUILDING INFORMATION n
EXISTING USE 1-1 {y 1 CA-L o P�‘cE f PROPOSED USE Et�(CAL o c F I C P_
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ 5 l 221 A C)0
SPRINKLERED BUILDING? )'YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? )(YES 0 NO
WATER SERVICE PROVIDER X LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
i
4•
U PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND 2 ,T1 1
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR ❑UNCOVERED?)
GARAGE ❑ CARPORT ❑
EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
NUMBER OF FLOORS
**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 furfures to remain.
MECHANICAL
Value of Mechanical Work$ (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORA E COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS FANS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS _...--• HOODS(Commercial)
COMPRESSORS FURNACES RANGES
DUClb 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(-rodet)
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.
V
NAME/TITLE A-°.. A .. DATE
—
(Si: ature) (tale)
RELATIONSHIP TO PROJECT 0 Owner ,Agent 0 Contractor 0 Architect D Other
lx0 •q US
n NEW ❑ADDITION ❑ALTERATION -REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES ❑NO BASIC PLAN? ❑YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑YES ❑NO
NEW ADDRESS REQUIRED? ❑YES ❑NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? ❑YES ❑NO DEMO PERMIT REQUIRED? ❑YES ❑NO
Bulletin#100—April 2,2007 Page 2 of 4 k\Handouts\Permit Application