07-103215 Federal way PERMIT Q - _L`. 3 _2
COMMUNITY DEVELOPMENT SERVICES REC i •SF MF CO ME EL PL DE EN P
33325'D AVENUE SOUTH•63 BOX 9718
APLI
CATI O TO
.253-835-2607;FAX 253-835.2609 RN
YYu�ii
wilily r.,qv f(ederolwntr.cnm ` N
TIte following is required information—an incomplete application will not be accepted. Please print legibly(in ink)or type.
CITY I)
S -PROPERTY INFORMATION -
SITE ADDRESS 1 /7V°O -h ('. ) { %Li/ ) _ SUITE/UNIT# ID i
ASSESSOR'S TAX/PARCEL# ?6 ad--Lar Q Q / () _ LOT SIZE (sf)
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
PROJECTaESCRIPTION (Providet\&2 .
etailed de tion of work included on this permit onlu)
1C rlG ;"
PROJECT NAME(Name of Business or Owner Last Name) Z{04 1 e ,
• I:PEOPLE INFORMATION
PROPERTY NAME I PRIMARY PHONE
OWNER (15 ( ) _
MAILING ARE CITY,STATE,ZIP E-MAIL ADDRESS
CONTRACTOR ComPA ME RICANT NAME
TS'
/ - + iitt 1 I' ,,, '�/M/_ -�}�,���/.lir(
PHONE.
L,t �I I Y� l'Oeol-ft-On
O 1 1. ` ' �� C 1 PH)NE � L '1(-//-
MAILING ADDRClsy5 `^ CI ,STATE,ZIP
�(1) U A k 2.-1.13 T r ,ACO »I c O,S'l )
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE N MBER
-9 8 - ‘cam-- t -oo 7_,-3 / . ( ) -
CON
CONTRACTOR'S REGISTRATION NUMBER
EXPI TION DATE
•I�
E-MAIL
ADDRESS
COPY of card ngolmd �•ltL each app ' UCv,p � aml/ (...//�/ ` 111 -D
APPLICANCQPpNYNAME APPLICANT V ` OFFI�PHpNE / ')//�.^�-
G0tt ' LC pa ILI/rll''
d I /' (�ItY IrA
// YSTq(cHNE /NSHIPTO``POJECT
FAX NUMBER
❑ Architect 0 Tenant 0 Agent 0 Other C° v-0/(„1-cr ( ) _
PROJECT NAMEPRIMARY PHONE E-MAIL
CONTACT ADDRESS
n) ( ) _
LENDER NAME PerRCW 19,27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
•` ,.;M.-DETAILED BUILDING INFORMATION ,'._.
EXISTING USE ?l"a '\ U PROPOSED USE A' -I a i •
EXISTING ASSESSED/APPRAISE,D/VALUE $ VALUE OF PROPOSED WORK $ ,l /OU.C 0
/IOU
BUILDING? (1/YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER KLAKEHAVEN 0 HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ArtAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
VgiPAIIIWillimIg*lzw3raill51"24ww. ,,
A , AREA DESCRIPN EXISTING PROPOSED TOT
AL
...,_
SQ.FT. SQ. FT. SQ. FT.
BASEMENT
FIRST
•
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0 .
EXISTING I PROPOSED I TOTAL TOTAL E><TSTIN65r TOTAL PROPOSED St
TOTAL sr
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
' - Ill FIXTIIRES.
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(commercial)
COMPRESSORS FURNACES RANGES
DUCTSGAS LOG SETS •REFRIG.SYSTEMS
; .
PLUMBING URINALS MISC(Describe)
BATHTUBS(or Tub/shower combo) LAVS(Bathroom Ratko)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS posey
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
ahof Feclcosts, expenses, and attorneys'fees incurred the investigation defense of
such
hclairmlessmt),e whicCityh may be mderaladeWay byas antoy person,anyclaim includ(ininguding the undersigned, and filed against the City of Federal
in Way, but only whereand 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.
e r
,�' /f�- DATE te"/ (2
NAME/TITLE r (Tide)
/65;
(S gnature)
RELATIONSHIP TO PROJECT 0 Own 0 Agent Contractor ❑ Architect ❑ Other
o NEW o ADDITION a ALTERATION o REPAIR a TENANT IMPROVEMENT.
BUILDING SHELL ONLY? o YES a NO BASIC PLAN? o YES a 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;2007
Page 2 of 4 k\Handouts\Permlt Application .