07-100140 a � •
RECEIVE
CITY OF D - 0 _c)Federal Way
. A142007 PERMIT
COMMUNITY DEVELOPMENT SERVIL S SF MF CO ME EL PL DE EN FP�'
33325 8nt AVENUE SOUTH•PO BOX 9711.8y �y C p/��//��_
FEDERAL WAY,WA 9806��OF FEDGt-A t PPLI CATI ON TD
253835'1607•FAX 2538
«II::>,n BUILDING DEPT.
The following is required information-an incomplete application will not be accepted. Please print legibly(in ink)or type.
• PROPERTY INFORMATION
SITE ADDRESS 6• 3 2 091 S (, SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# Z 'I 2 3 Z 0 - 0 0 s- .) LOT SIZE(sj)
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 ok FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlu)
flDd/RelocAie he, ,Ds Pot New 441/J A•)4 Ca;L . 6,1^1D
PROJECT NAME(Name of Business or Owner Last Name) 1 ' \0( 0 —
PEOPLE INFORMATION
PROPERTY NAMETIN-3
PRIMARY PHONE
OWNER 'Ark (14-1) s69 -2970
MAIDDRESS CITY,STATE,ZIP E-MAIL ADDRESS
s 3 Z=*I eve, 6. L,A•414,064 401 Yril9
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Ael-I/tvcc F,I'e. ptofeJ ell X,n o (Zoe )682 -4(03(0
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
P 8 o 411 PPeS'17>4) I,IJ•q 5'8°S0 (Z ab ) 2 76 -7?
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXI'IRATION DATE FAX NUMBER
20-O3 - 1e'S4l -Bo13L OevithLi 2061 (zed.)61'2 -47p'l
COPY of cera requires CONTRACTORS REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
with each application => I\e L 14 FP /92 L,1 12-31- 97
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
S1�� 4 �1 Qsve,
MAILING RESS CITY,STATE,ZIP CELL PHONE
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect ❑Tenant 0 Agent Other CoAirm-6.- Dr ( ) -
PROJECT NAME PRIMARY PHONE E-MAIL ADDRESS
CONTACT Ti, /17 Qv I)C/,) (ze(0) 271? -4'q(o )
LENDER NAME Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
• DETAILED BUILDING INFORMATION
p
EXISTING USE D7 1 C e S P/tGt. PROPOSED USE 6).-/-4-C 4)09i4 c e.
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 7, D PO
SPRINKLERED BUILDING? X YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? k YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
• PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND \`�
THIRD ,y
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR ❑UNCOVERED?)
GARAGE ❑ CARPORT ❑
EXISTING PROP TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
a 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 CO'Y OF BID OR ESTI TE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPO'4(TIVE COOL GAS PIPE OUTLETS WOODSTOVES
BBQS FANS / GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLAC A NS" HOODS(commercial)
COMPRESSORS FURNACES ', RANGES
DUCTS GAS LOG,: REFRIG.SYSTEMS
PLUMBING
BATHTUBS(or Tub/shower combo) VS(Bathroom Sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(Iwo
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 the city,including its officers and employees,upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLEDATE /'' /D.O 7
+nature) (Title) •
RELATIONSHIP TO PROJECT 0 Owner 0 Agent Contractor 0 Architect 0 Other
FOR OFFICE USE ONIY
❑NEW ❑ADDITION ❑ALTERATION ❑REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES o NO BASIC PLAN? ❑YES ❑NO
ZONING DESIGNATION CHANGE OF USE? ❑YES ❑NO
NEW ADDRESS REQUIRED? ❑YES ❑NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? o YES ❑NO DEMO PERMIT REQUIRED? ❑YES o NO
Bulletin#100-January 1,2007 Page 2 of 4 k\Handouts\Permit Application