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CITY OF . APR t\ 0 7 LO k 0' ( . _
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Federal ay �PE,RMIT
COMMUNITY DEVELOPMENT SERVICES SF MF CO ME EL PL DE EI' FP
333258TH AVENUE SOUTH•PO BOX 971vny OF F" YICATION
FEDERAL WAY,WA 98063-9718 BUILD1
• Ariii/A
253-835-2607•FAX 253-835-2609 M
www.cityoffederalway.com
The ollowin• is re•uired in ormation-an incom•fete a••lication will not be acce•ted. Please •rint le•ibl (in ink)or
1/74.
�• PROPERTY INFORMATION
SITE ADDRESS SGS) �n h Pa-CI /i G (.L1// SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# - � 7 e-,--041/ LOT SIZE(s�
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) E=eef ./r /.V 4y h 6 /3 /G[/L A,
(Attach separate page for lengthy Ijyal description)
• PROJECT INFORMATION
TYPE OF PERMIT D BUILDING 0 PLUMBING 0 MECHANICAL
Li DEMOLITION ELECTRICAL CIENGINEERIN RE PREVENTION SYSTEM
PROOM((Provide description worked permit
_T5/ dhcc " f/ C � w �rnyTPr:1
'
PROJECT NAME(Name of Business or Owner Last Name) c(/�S S , s - old �-
• PEOPLE INFORMATION
PROPERTY NAME �9 PRIMARY PHONE
OWNER ies""" (O f ) LjS 3 -Cave
MAILING ADD S CITY, TATE,ZIP
¶/s /iiI4i Alig a,,/3c /3�//e 'tet / ,a.-• Tea°‘*--
CONTRACTOR
CONTRACTOR COMPANY NAME APPLICANT NAME) OFFICE PHONE
Tact i'c /-4,-€-IS ec��'4 I.", _ Da,..eijvs7•cC ( )7 e1 - 38/5
MAILING AD KESS / I CITY STATE,ZIP 1 CELL PHONE
�c ' o/ PLcc S . �e•� /c 4,11 ' '1 I(iv ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
CL-.G 1-1 0 ' `L �-B L ,2 /3/ / 006,& --- b -2160
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
t o 4 . P F s t .7 3 f' Ll / /
APPLICANT CO "NAME i , APPLICANT NAME OFFICE PHONE
I r 1
1 ( )
' G ADD• CITY,STATE,ZIP CELL PHONE
( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT NAME PRIMARY PHONE1 E- L ADDRESS
--.�s�v CF" c,5 �-<< (ate.) ?J(. - 2 14 01,16 QP cs,d z
LENDER Per RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ •C/C)
SPRINKLERED BUILDING? u YES n NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 11 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
• •
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
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 $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commercial) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLILIS
PLUMBING
BATHTUBS(or Tub/shower combo) SHOWERS WATER CLOSETS('toilet) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAYS(Bathroom Sinks) VACUUM BREAKERS ELECTRIC WATER HEATERS
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,including its offi rs and employees,upon the accuracy of the information supplied to the city as a part of
this application. t`
NAME/TITLEDATE 7 -2 --e.-/‘
(Signature) )(Contractor
(Title)
CY'
RELATIONSHIP TO PROJECT ❑ er ❑Agent Contractor ❑Architect ❑ Other
FOR OFFICE USE ONLY
NEW r-ADDITION ❑ALTERATION c REPAIR n TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES ❑NO BASIC PLAN? o YES c NO
ZONING DESIGNATION CHANGE OF USE? ❑YES a NO
NEW ADDRESS REQUIRED? o YES n NO UP/SEPA/SU? u YES c NO
PLATTED LOT? ❑YES ❑NO DEMO PERMIT REQUIRED? n YES E NO
Bulletin#100—January 1,2006 Page 2 of 4 k\Handouts\Permit Application