03-101718 •
CONSTRUCN PERMIT APPLICATION
CITY OF �.✓ APPLICATION NUMBER:
Federal Way - 0171 13.`
APPLICATION NUMBER:
APPLICATION NUMBER:
"The following is required information-Please print(in ink)or type"
37)\1
Please
Please note: Electrical, Fire Prevention stems and Engineering permits may require a separate application. 1
- • ►' PROPERTY INFORMATION
SITE ADDRESS: 5o. ( /� j.p S
Z � ! , 6 '�''Yu � LA--i ASSESSOR'S TAX/PARCEL #:
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
PROJECT INFORMATION
TYPE OF PROJECT(This application): o BUILDING o PLUMBING ❑ MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING o FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description): j�flaa'
PROJECT NAME: `'-14
; F'PEOPLE INFORMATION
PROPERTY OWNER: NAME: J / ` DAYTIME PHONE
1�.a o) c� ` Lc,► cel uJ cGf i )
MAILING ADDRESS(STREET ADDRESS;CITY,STAll,ZIP• 5 �� u ! D�� j
62 v i3s
CONTRACTOR: NAME: 1 ^ DAYTIME PHONE:
MAILING ADDRESS(STREET ADDRESS;CITY,STATE ZIP): !. EVENING PHONE
CZ53) /'�� -7696
I CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: I FAX NUMBER:
i ( )
CONTRACTOR'S REGISTRATION NUMBER:
EXPIRATION DATE:
(copy of card required)
APPLICANT: I NAME: /-1 LA.) DAYTIME PHONE:
I IVJ
MAILING ADDRESS(STREET ADDRESS; ITY,STATE,ZIP): )
EVENING PHONE
RELATIONSHIP TO PROJECT:
FAX NUMBER
❑ ARCHITECT ❑ TENANT o OTHER( DESCRIBE): ( )
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: o PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
. --111 DETAILED BUILDING INFORMATION
EXISTING USE: EXISTING BUILDING ASSESSED/APPRAISED VALUATI $ 3606 e
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: $
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED:o YES 0 NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN LI HIGNLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER: o LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
**NEW RESIDENTIAL CONSTRUCTION 00** •
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
■ PROSECT FLOOR AREAS
FLOOR EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
B EMENT
FIRST
SECOND
THIRD
FOURTH
OTHER FLOORS(DESCRIBE
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
■ F1URES
Indicate nu r•er of each ty e of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) AS LOG(S) REFRIG.SYSTEM(S)
BBQ(S) FAN(S) HOOD(S) WOODSTOVE(S)
BOILER(S) FIREPLACE INSERT(S) RANGE(S) MISC.( )
COMPRESSOR(S) FURNACE(S)
DUCT(S) /•/// GAS PIPE OUTLET(S) HEAT SOU'ItNeErNy ELECTRIC o GAS
PLUMBING
�ATHTUB(S)
LAVATORY(S) URINAL(S) WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINK(S) WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
1/ 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,induding its officers and employees,upon the accuracy
of the information supplied to the city as a part of this application. �^ I �r
NAME/TITLE: (�At- � .Ji DATE: ,. (.�`�3
D PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
FOR OFFICE USE ONLY:
.57`NEW -•.•`ADDITION O ALTERATION*, ❑ REPAIR ❑TENANT IMPROVEMENT
1 -'LOT SIZE•
CENSUS,`CODE���x`���.�5° � :,._ ��'" ��v�=
:ZONINGDESIGNATION • ' Vi BUILDING SHELLONLY?i ❑YES ' . ❑'NO -
=COMP PLAN DESIGNATION is . ,. ;BASIC PLAN? = 'D YES ❑ NO •
.SECTION *k TOWNSHIP_; ., RANGE t" 'NEW ADDRESS REQUIRED? ❑ YES ❑ NO
'PLATTED LOT?:' -❑YES;.;❑;NO CHANGE OF USE?, YES •❑ NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH•PO BOX 9718•FEDERAL WAY,WA 98063-9718•253-6661-4000•FAX:253-66114129
www.dtvoffederatwav,com