07-105447 cta or
at er. IWay RFCEIVEC PERMIT - -� fie_
COMMUNITY DEVELOPMENTSERVICES
SF MF CO ME EL PL DE EN
33325 FEDERAL
WA ,WA 9.PoBOX
� T 0 .1 APPLICATION I FEDERAL WAY,WA 98063-9718 7! TD
253.835.2607 FAX 253-835-2609
nnutu,dttlofederolwa ll.cop
vITY OF FLDtt-'siAL
The following is req> 1t a-an incomplete application will not be accepted. Please print legibly(in ink)or type.
-.PROPERTY INFORMATION
SITE ADDRESS_ 21 9 5 3,2,-- A SUITE/UNIT#-
ASSESSOR'S TAX/PARCEL# _ea 7 Q - ..7_ LOT SIZE Of)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION
•
TYPE OF PERMIT 0 BUILDING 0 PLUMBING. ❑ MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING ,FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
PROJECT_NAME(Name of Business or Owner Last Name) P' • P - -
U PEOPLE INFORMATION
PROPERTY NAME / PRIMARY PHONE
OWNER /0/ A 1- 3-eGV9 ( . ) - _
MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS
3945 .,i'lf /511 f ti r;:14%., dig)" 9i
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
C 'T-6y� r;415'4';� a� ( ) _
MAILING ADDR S S L�� / CfT/Yp,STATE,ZIP CELL PHONE 51.2
e fi
CITY 2--dERAL WAY BUSINESS LICENSE N MHER d 6 .EXPIRATION DATE FAX BER
(-1-',:'
/�" CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
U r<,. n (2 ) e - 1.-416
MAILING ADDR'SS C ,STATE,ZIP CELL PHONE
-57 RELATIONSHIP uCpl e-i _re�1 ' i�'e AIR' 7d''', 1 F(AX NUM) _
ER
❑Architect 0 Tenant ❑Agent 0 Other ( ) _
PROJECT NAMES PRIMARY PHONE E-MAIL ADDRESS
CONTACT F7'4 k 500/7 / ( ) 9.29 _Z V
r
LENDER NAME Per RCW 19.27.095:
ider information is required if project value exceeds$5,000 •
MAILING ADDRESS : CI ,STATE,ZIP PHON
( _ �,
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOUSE
CN
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ I f:)
SPRINKLERED BUILDING? 0 YES 0 NO FIRE PPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ FIIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER o LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
'R e JECT FLOOR AREAS
AREA DESC ION .EXISTIN k PROPOSED TOTAL
SQ:FT. SQ.FT. SQ.FT.
BASEMENT
. \\\ "\\\
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE❑ CARPORT 0 —
NUMBER OF FLOORS 87QeriSO PROPOSED TOTAL TOTAL LQBTINe Sr TOTAL PROPOSED ST TOTALS?
"NEW HOMES()far* NUMBER OF BEDROOMS ESTIMATED SELLING PRIG $
(♦ 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 QF 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 INSERTSOODS)commercial)
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS(or Tub/Shower Combo) LAVS(aomrooms.ks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS owe)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS
SIGNATURE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best of my
knowledge, the information submitted in support of this permit application is true and correct.I certify that I will comply with all applicable
City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the issuance of this permit
does not remove the owner's responsibility for compliance with local,state,or federal laws regulating construction or environmental laws.
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, 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 applicati-n.
SIGNATURE: DATE �f .-/—e) •
_
Property Owner and/or Authorized Agent
o NEW o ADDITION o ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? o YES a NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? a YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
•
Bulletin#100-August 16,2007 Page 2 of 4 . k\Handouts\Permit Application