07-100203 CITY OF r✓'' ..
41
Federal Way ECE1�° 1 PERMIT _
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COMMUNITY DEVELOPMENT SERVICES SF MF CO ME EL DE EN FP
333258TH AVENUE SOUTH•PO BOX 9718 (, T /'y t i
FEDERAL WAY,WA 98053-97/8_IAN 2 ZU 1` TD /
253-835-2607•FAX 253-835.2609��'- 1 'P L I �,A 1 I O N at. i
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CITY OF FEDERAL WAY
The following is req>dtrycr? n-an incomplete application will not be accepted. Please print legibly(in ink)or type.
S PROPERTY INFORMATION . .
SITE ADDRESS 2--22Y) s /��'2.0 .51- SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# �' �- 4 - e e) LOT SIZE (s)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION .
TYPE OF PERMIT ❑ BUILDING ,,10 PLUMBING ❑ MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlq)
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PROJECT NAME(Name of Business or Owner Last Name) -7.--,/i p C 'i� Gti 1�lo/)
it PEOPLE INFORMATION / �'/
PROPERTY NAME
`/ �y,�� PRIMARY PHONE
OWNER ily/.f.�� . �f&/Y.. i�/ / . ( ) -
MAILIN ADDRESS / CITY,STATE,ZIP E-MAIL ADDRESS
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CONTRACTOR COMPANY NAME APPLICANT NAME l OFFICE PHONE
�'//�/"} ,9.r- -14--L e,4/9 -,e/c7 t- X1/,,: c41.44,7 (moo )1-3 - .
• MAILINGAVDRESS //N/,!/ CIT ATE,ZIP CELL PHONE 2
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CITY OF E ERALWWAY BUSINESS LICENSE NUMBER�� �EXPIRA ON DATE FAX NUMBER ?Y - J 6,2
A-/604-11- of C Z - 3i- 0'7 ( ) -
COPY of cord requiredCONTRACTORS REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
with each application I
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APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE "—...r-3{-7:11
AP
MAILING DRESS �4.. CITY, TE,ZIP / / CELL PHONE g
�S`-i�.�' Sr 17.f . '/ /y i-1 i 4 I// ( -'6 ) ',P/ -
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RELATIONSHIP TO PROJECT FAX NUMBE Architect o Tenant ❑Agent /7 Other ( ) -
PROJECT NAME PRIMARY PHONE E-MAIL ADDRESS
CONTACT (--01"\-kr /4--( ( )
LENDER NAME Per RCW 19,27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
.y ' '° U.iDETAILED.BUILDING INFORMATION .
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EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ • - VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? • 0 YES 0 NO FIRSVPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
4 :t< Y;,,•aH 'S,,a 3l:.. 34.E yt � t 4 •
_S .`s ; 11)x•..0 r S f a .< 2 ` 2 ••t fit .,..mm..mn , ' .nnrrm., .
AREA DESCRI. N EXISTINGO PROPOSED TOTAL
BASEMENT ` .4.
T — -
SQ.FT. SQ. FT. SQ.FT.
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
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(commercial)
COMPRESSORS FURNACES RANGES
DUGS; GAS LOG SETS REFRIG. SYSTEMS
•
PLUMBING
BATHTUBS(or Tub/Shower Combo) 2- LAVS(Bathroom Sinks) / URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS 3 WATER CLOSETS(Toner)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS 2 ;[�cLY P) rm
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.
NAME/TITLE <" — DATE - 2(Signature) (Title)
RELATIONSHIP TO PROJECT 0 Owner o ent Contractor o Architect ❑ Other
o NEW o ADDITION ❑ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? ❑YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES a NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin 4100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application