07-103177 CITY OF AI D ` / 7
Federal WayRECEiVE PERMIT _i_ --444,-----��
COMMUNITY DEVELOPMENT SERVICES MF CO ME EL PL DE EN (Y Y
33325 8T"AVENUE SOUTH•63 97 71,N 112007A P P L I C AT I O N ��
FEDERAL WAY,WA 98063-97 TD -
_ / /
253-835-2607•FAX 253-835-2609
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k,`r OF FEDERAL W A'
The following is reiiiiiiitid U1dih ii1ion-an incomplete application will not be accepted. Please print legibly(in ink)or type.
0 PROPERTY INFORMATION
/' f 3 /�
SITE ADDRESS_ 1l j ✓v a 1. I, 9'` k {, SUITE/UNIT#_ ,4 l 01
ASSESSOR'S TAX/PARCEL# I 5 Cr C- O C U LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
NI PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING `LV FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this it on
j -i1v\t' �� pe5it 1 5Nti75 s
PROJECT NAME(Name of Business or Owner Last Name) "-) 11)e k lä- d R i LSA. U
• PEOPLE INFORMATION
PROPERTY NAMEi�r�1 k %rf` I`PRIMARY PHONE
OWNER JJ (�,LJ
MAILING ADDRESS CITY TATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANYLNAME APPLICANTAAtt- NAME OFFICE PHONE
1//J ' Th Lam- � ) \ )�A t I � ( � /9 ( )
MAILING ADDRESS O 1 1°_,1 TTY,STikT kd P k` /fir/,f Y .. CELL-PIH NeE�` �`� - �.
CITY OF FEDERAL W,Y BUSINESS LICENS NUMB EXPI�ONtD(ATTE FAX NUMBER �"
COPY of card required CONTRACTOR'S REGISTRATION ��NUMBER7seB
\\ - EXPIRATION DATE q E-MAIL ADDRESS
with each application I ' fl I \� K' J C� r)tAPPLICANT COMPANY NAME ry��j`/\ V APPLICANT NAME �l//� OFFICE PHONE
56 111 (( )
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX.NUMBER
❑ Architect ❑ Tenant ❑Agent El Other ( ) -
PROJECT NAME PRIMA PHON _ •� E-MAIL ADDRESS
CONTACT �wke5 '0\j - LoO) rJ hi,i(� ��
LENDER NAME �..i Per RCW 19.27.095: 7
Lender information is 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 $ 22Q00
SPRINKLERED BUILDING? 0 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
Al
AKB:ADESCKIi'TioN EXISTING PROPOSED TOTAL
SQ.FT. SQ. FT. SQ. FT.
BASEMENT
II
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑ COVERED OR 0 UNCOVERED?)
GARAGE D CARPORT 0
4•
EXISTING PROPOSED TOTAL TOTAL EXISTING Sr TOTAL PROPOSED Sr TOTAL Sr
NUMBER OF FLOORS
**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$ (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(commerdor)
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS(orTub/shower combo) LAVS(Bathroom Sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(toilet)
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 filed against the City of Federal Way,but only where such claim
arises out of the reliance of • city, including its officers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
7•
1
NAME/TITLE ` cAv 1, �/� DATE 7 /
V Sign f= (Title)
RELATIONSHIP•/P• ' JEC ❑ trwner ■ Age, ❑ Contractor ❑ Architect ❑ Other
i M k�PSG�U E O Litt.,...•. 't,.
❑NEW ❑ADDITION o ALTERATION ❑ REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES o NO BASIC PLAN? a YES o NO
ZONING DESIGNATION CHANGE OF USE? o YES a NO
NEW ADDRESS REQUIRED? o YES 0 NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES a NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#(100—April 2,2007 Page 2 of 4 k\Handouts\Permit Application