07-102263 •C1fY OF 0"4.4:0,'"' , 0 V (0 3
. - Federal Way RECEI -1-11- 1-4,R M I T �� —
SF MF CO ME EL PL DE EN FP
COMMUNITY DEVELOPMENT SERVICES
?33258T^RAL'WESOUTH•POBOX 9718APR 2 6 2 PPLI CATI ON
FEDE.RAL�WAY,WA 98063-9718 l'1 (� TD / /
0253-835-2607•FAX 253-835-2609
IVWW.eilr pf ederiilwr com CITY
'JOF OF t1P R AL WP
. The following is requi/ ormatio T- aPn incomplete application will not be accepted. Please print legibly(in ink)or type.
S PROPERTY INFORMATION
SITE ADDRESS4' -&)(-4-11 & -, (1......TITE)WIT# , DI
ASSESSOR'S TAX/PARCEL# r 5 0_0 _5 0- 0 0 U LOT SIZE (sf
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
❑ DEMOLITION 0 ELECTRICAL 0 ENGINEERING 14 FIRE PREVENTION SYSTEM
f -
PROJECT DESCRIPTIION(Provide detailed description of work included on this permit onlq))'
PROJECT NAME(Name of Business or Owner Last Name) ,4 3 - .6-61,1 z..1,�,GK6.6'.41 Ark—
, PEOPLE INFORMATION
PROPERTY ME
PRIMARY PHONE
OWNER \/ c��/�1I (Ja
NG ADDRESS ' I� CWei,ZIP, )�-�l_�►—� E-MAIL ADDRESS
0
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
rim '4 OA Is Al i'. .L A '-`. .11 la / 6,-77' i 0- .w &fI$
7—MIN ADDRESS — ��-ATE,ZIP /'_�_;_ p CELL ONE
ED r e (vJ�(X'1?i1�'-�L.1►Y
RAL BUSiNES L E NUMBER `^ RAT TE �AX NUM ER
\ — C . lCTRACTORS REGISTRATION UMBER - EXP1 li ON E-MAIL ADDRESS
wlth each appllutlon Cc)p
s.7..v.A.F.„.20:iti (IF
APPLICANT OMPANY NAME - ANT NAME
��',`,J�� `r�1 APPLIC
/�(/� "/��\ �'''�/��j ! OFFICE PH/VON�,E� (�
A LIN ADDRESS �� ���� -CI ,STATE IP' Y.IS��.I, CON '- lJ
a�y E
IONIP TO RFT OJECT N't• E \" l ll I :1( W"' 1 ( )
FAX NUMBER •
❑ Architect 0 Tenant 0 Agent 0 Other ( e y' _i Q'`\b
PROJECT NAME r PRIMARY PHONE E-MAIL ADDRESS y
CONTACT ` �/1 � LCt PS) 0 ']MD
LENDER NAME 1 ��J WL • PerRCW 19,27.095:�J
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
(
,.,-,:-.:.•:t:-1:,;...1:!.';',-:.......,.I.-DETAILED BUILDING INFORMATION .
EXISTING USE ETA 1 i~ SEAR LL PROPOSED USE ()C^F='l C;..i 1/4.S G • •
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 02 1 E LI-0
•PRINKLERED BUILDING? X YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ElYES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
P'( Y •
.W y,p., .a 77... `.. �� TF 4 1 V ``i. i i.4 r:. • • • '1'4.D/' Y< '`,'' t
„y�gF JTR tt tF0 82ji C,L- r Ia i1, . r .� , - t:.' -
r(; a,.mMia .. ntxs •• ... ..0 v .. .,,... ..:v amvvmnmmrmna+avmm •:=.•=- ',, ,:;',.,7`
ranimnnrM.nuvN/n+v mw.n/., smen .rvmn.+nm�M ... r..au.mrrnm
4 AREA DESCRI N EXISTINGW PROPOSED TOTAL
SQ. FT. SQ. FT. SQ.FT.
BP SEMEIIT
w
IRST
3,03J 5c>Zrf. 1 D, 542x1.
.ECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL TOTAL EXISTING ST 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 • ••' TOVES
BBQS FANS GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(co.. pail
COMPRESSORS FURNACES
DUCTS; GAS LOG SETS REFRIG.SYSTEMS , ;,, .
PLUMBING
BATHTUBS(orTob/shower Combo) LAVS Ic . oom Sinks) URINALS MISC(Describe)
DISHWASHERS
DRINKING FOUNTAINS
RA'i"NWATER SYST VACUUM BREAKERS
SHOWERS WATER CLOSETS rose
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/TITLE / �1 /�.L_-- P(Li;.,t T M
- 14+4iTi... c� DATE `T-2 IL, - 4'
i�i 'Signa a*e11 (Title)
RELATIONSHIP TO PROJECT ❑ Owner 0 Agent Contractor 0 Architect 0 Other
r :''
o NEW o ADDITION a ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? E YES o NO BASIC PLAN? o YES a NO
ZONING DESIGNATION CHANGE OF USE? a YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES a NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
•
Bulletin##100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application .