04-101931 '` ,ECEIVED
MAY 1 8 2004 CONSTRUCTION MIT APP TIOrN,
CITY r ',, ERALAPPLICATION NUMBER: L' 1 - L!J i 1 -CD
Federal Way BUILD NG DEPT.AY -
APPLICATION NUMBER:
APPLICATION NUMBER: -
**The following is required information—Please print(in ink)or type**
Please note: Electrical,Fire Prevention Systems and Engineering permits may require a separate application.
• PROPERTY INFORMATION
rotit'IWAvSITE ADDRESS: /0 �.. ; �..v 'q i j t'l_t �J — "f _, 1'-'
LL.11 • SESSOR'S TAX/PARCEL#:
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARAT 'ESCRIPTION IF LENGTHY):St)I A '
1716 d.i *-Q-1(1 -11 (A 1i..- Pi (1 - GCcorn O. •-ki..,
-k`YN ( uS /S cLir Ce i
• PROJECT INFORMATION
TYPE OF PROJECT(This application): o BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
o ELECTRICAL 0 ENGINEERING -FIRE PREVENTIONSYSTEM
PROJECT DESCRIPTION(Provide detailed description): r 1� 4 l 'I t_. 4ririze Stifc
PROJECT NAME: (3 i CO
• PROJECT INFORMATION
PROPERTY OWNER: NAME: DAYTIME PHONE:
( ) -
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP):
CONTRACTOR: rn)441 ,-ct
/1 ` DEQ PHONE: - �®
''''''.-Jt-L'ark
�AR5 ce E55(STREET EyS;CITY,STAT IP): '��"(�/-�'�`'(/\1�141 %vet-EVENING PHONE: -
CITY OF FEDERAL WAY BUSINESSLICENSENUMBER`. `�,/ • „ r 0 013 FAX NUMBEJ`R.
-
CONTRACTOR'S REGISTRATION NUMBER: m (� j /� EXPIRATION DATE:
(copy ofcard required) s h_) /� i _ / 3 ( y r // / C/�1 L4
APPLICANT: n10)—kr)
J,h - - S �V DAYTIME PHON g
"'�' - is,
TNy DRESS(STREET ADq�2ESS;CITY STATE,ZIP): EVEN HONE:
�( L�Li f --Z( ) C ( ) -
RELATIONSHIP TO PROJECT: FAX NUMBER:
o ARCHITECT ❑TENANT o OTHER(DESCRIBE): ( ) -
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: o PROPERTY OWNER ❑APPLICANT TONTRACTOR
• PROJECT INFORMATION
EXISTING USE: EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: $ 4/ lL7 0
SPRINKLERED BUILDING? YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: ❑PES o NO
WATER SERVICE PROVIDER: o LAKEHAVEN ❑ HIGHLINE ❑TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER: o LAKEHAVEN ❑ HIGHLINE o PRIVATE(SEPTIC)
' + •
••
**NEW RESIDENTIAL CONSTRUCTION ONLY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
• PROJECT FLOOR AREAS
FLOOR EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
OTHER FLOORS(DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
• FIXTURES
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS 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 SOURCE: ❑ ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S) LAVATORY(S) URINAL(S) WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) o ELECTRIC ❑GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINK(S) WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
• 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 daim(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 o the city as a part of this application. r �//
NAME/TITLE: I C7Y I ( ) DATE: `i/i / 04
o PROPERTY OWNER o APPLICANT —9.JCONTRACTOR
FOR OFFICE USE ONLY:
o NEW o ADDITION ❑ALTERATION ❑ REPAIR ❑TENANT IMPROVEMENT
CENSUS CODE: LOT SIZE:
ZONING DESIGNATION: BUILDING SHELL ONLY? ❑YES ❑ NO
COMP PLAN DESIGNATION BASIC PLAN? ❑YES ❑ NO
SECTION TOWNSHIP RANGE NEW ADDRESS REQUIRED? o YES ❑ NO
PLATTED LOT? ❑YES ❑ NO CHANGE OF USE? o YES o NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH•PO BOX 9718•FEDERAL WAY,WA 98063-9718•253-661-4000•FAX:253-661-4129
www.citvoffederalway.com.