08-100758 RECLAVED ���
1"•OF
Fera'Way oFE RMIT
COMMUNITY DEVELOPMENT SERVICES FEB 1 5 2 S SF MF CO ME EL PL DE E 6
3332E 8m
DER L SWATH•63 BOX 9718 A 'P TIO N
FEDERAL WAY,WA 98063-9718 � � / /
253-835-26076-*1FAX 253-83149,.Y OF FED A
The following is required informaG -Sn incomplete application will not be accepted. Please print legibly(in ink)or type.
MI PROPERTY INFORMATION
7
SITE ADDRESS ^fi t �2t ce Ave_ S SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# ZS '2... .L C 3 - 9 Q _5 C LOT SIZE(sf
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
IAe.seporadeP.Mfor r 9thYWWIdescr4&,B
In PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION IP ELECTRICAL 0 ENGINEERING bir FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlu)
1 to S A-ix,0 VL�e vv c,,c,,,--eat&r w\ St lGN\.•
PROJECT NAME(Name of Business or Owner Last Name) Tt,�t 1^ 1e\,•I is,
in PEOPLE INFORMATION
PROPERTY NAME• PRIMARY PHONE
OWNER ( )u'� 3 kl i . ( ice ( ) -
MAILIN ADDRESS CITY,STATE.ZIP E-MAIL ADDRESS
CONTRACTORCO ANY NA/
APPLICANT NAME OFFICE PHONE
WS �� _ Kr I S ClO44 Acle* 053 1 875 -3o(s.
MAILING ADDRESS CTIY.STATE.ZIP CELL PHONE
16 1IL>
CITY OF FEDERAL WAYS ICEN U ER EXPIRATION DATE FAX NUMBS)tel _glt.{,d.
�/ DZJ " � (ZSR )415 - 3025
(272
COPY of card required
CO ITS REGISTRATION NUMBER EXPIRATION DATE E MAIL ADDRESS
with each Implication L)EST c r s Q1 S tot__ Z (0 /2.2401 k/15.t'en^e r'®Co a t:aa L.ASI'
APPLICANT COMPANY NAM APPLICANT NAME OFFICE PHONE
k."..14.S. S re
( ) -
MAILING ADDRESS CITY.STATE.ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect o Tenant o Agent )(Other E. C. ( ) -
PROJECT N PRIMARY PHO E E-MAIL ADDRESS
CONTACT d'•t.S ( OAA.er c�-S31 b-lc - 301 6 Kct5. Co irte.-c CoMlca sL".#4
LENDER NAME Per RCW 19.27.095:
Lender information is required tf project value exceeds$5,000
MAILING ADDRESS CITY.STATE.ZIP PHONE
( ) -
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE 7
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ (,act)
SPRINKLERED BUILDING? o YES ❑NO FIRE BION SYSTEM PROPOSED/REQUIRED? o YES o NO
WATER SERVICE PROVIDER ❑LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑LAKEHAVEN ❑ HIGHLINE ❑PRIVATE(SEPTIC)
■ PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
+ SQ FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR C UNCOVERED?)
GARAGE In CARPORT ❑
EEisnm PROPOSED TOTAL TOTALJEWG SP TOTAL PROPOSED SP TOTAL SP
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 fixtures to remain.
MECHANICAL
Value of Mechanical Work $ (A COPY OF BID OR ES77MATE 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 icomm,,wa,l
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS tor Tub/Shower Combo) LAYS(Bathroom sini ) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS V
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 flied against the City of Federal Way,but only where such claim
arises out of the reliance of the city, lading its officers and employees,upon the accuracy of the information supplied to the city as a part of
this application. ,�y� j�
NAME/TITLE 7( Signature)
Polar /' L--- DATE 2111 /Q
(title)
RELATIONSHIP TO PROJECT ❑ Owner ❑Agent ❑ Contractor ❑Architect ❑Other
FOR OFFICE USE ONLY
o NEW ❑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? ❑YES o NO
NEW ADDRESS REQUIRED? ❑YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? ❑YES o NO
Bulletin#100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application