07-102690 Federal Way RECEIV
P F,R VI I To1 F MF CO ME EL PL DE ENO
;
COMMU,77 I'DEVELOPMENT SERVICES
33325 IEDERVENUE SOUTH•PO BOX27.1§,, 1 s 20 ?P L I C AT I O N /._,..........„........
"� ;FEDERAL WAY,FAX
53-8 3-2609 TD
'253-835-2607•FAX 253-835•?609
unuw.riI,ioffederal wa u.com
CITY OP'FEOERA y
• The following is re4Witip+ �n- n incomplete application will not be accepted. Please print legibly(in ink)or type.
. ■ PROPERTY INFORMATION .
SITE ADDRESS ':)-1....Z0 uhC, �` et'' I/UNIT# cl V` -
i
ASSESSOR'S TAX/PARCEL# __\_Z - ), 8- 01 3 - -(:) �� 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
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
adcllyetcpror intaas ` •nc1.�o ural e + oti l l
PROJECT NAME(Name of Business or Owner Last Name) Q€ N ,0_` �/C }.-
. ... . III PEOPLE INFORMATION ','..._,,,4'---=`
PROPERTY NAME / ',, PRIMARY PHONE
OWNER O QU CC r// ' y� ( ) _
MAILING AD ESS CITY,STATE,ZIP E-MAIL ADDRESS
411) CONTRACTOR ,OMPANY NAME APP.CANT NAME OFFICE PHONE
\IL
ILI ADD7{ES �‘lisA,a CIT'. A E,ZIP g�� !��` C L P ONEI
� � RA �B ESS LNSE NUM R EXPIRATION DATE , FAX NUMBER
eopv or e.ra regalrea CONTRACTOR'S REGISTRATI N NUMBER EXPIRATION DATE . E-MAIL ADDRESS
wune.h.ypuo.ao. I b61.4( 1--- wi .��it 1O -.5--ot3 .
APPLICANT t OMPANY NAME +�n APP ICANT/N�AME J! OFFICE PHONE
l A RESS V l'4 C A' \� ' .J`" 'l C91;)io)ci� : ar @D
LATIOSHIPTOPROJECT I�.Lo 0 ( )
., FAX NUMBER
o Architect ❑ Tenant ❑Agent ❑ Other 1,fID
,\t'/,1 %_ mill (3l.) AiY-_ ( n` -
PROJECT NAME PRIMA•' • ONE
E-MAIL ADDRESS
CONTACT ep I, (q•+ 1- ( ) _
LENDER NAME •PP�� Per RCW 19.27.095: .
-bendier`info rmatMii is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PH NE
- ( )
` U.-DETAILED BUILDING INFORMATION -
EXISTING USE PROPOSED USE •
EXISTING ASSESSED/APPRAISED VALUE $ - _ VALUE OF PROPOSED WORK $ Ur I CD
elSPRINKLERED BUILDING? 0 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑PRIVATE(SEPTIC)
AREA DESCROON EXISTING PROPOSED TOTAL
• SQ.FT. • SQ. FT. SQ.FT.
BASEIViENT
FIRST
4, 1 AO Sa.trC
•ECOND
THIRD •
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT ❑
EXISTING PROPOSED TOTAL TOTAL EXISTING SP TOTAL PROPOSED Sr _it'.4i."'
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
IXTUBES
. 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) `.'(c' s fQ1a‘u 4*&..
COMPRESSORS FURNACES RANGES
DUCTS. . 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(roller)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
II 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. n
NAME/TITLE �l/ ----- Pit a3NG'f to 0S,(4%470 - DATE 3— Up-t'}
(Signature) (Title)
RELATIONSHIP O PROJECT 0 Owner 0 Agent 'Contractor 0 Architect 0 Other
o NEW o 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? 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? ❑YES o NO
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Bulletin 4100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application