07-104313 Nth, ' h _ l0Li .3 ( 3
CITY OF
Federal WaY RECEIVE. PERMIT
COMMUNITY DEVELOPMENT SERVICES
MF CO ME EL PL DE EN FP
333258THAVENUE WA 9•PO 9718 AUG 0 3 APPLICATION
FEDERAL WAY,,WA 98063-971971 8 TD / /
253-835-2607•FAX 253-835-2609
www.cituoffedernlwau.com
CllYrThe following is requ r an incomplete application will not be accepted. Please print Iegibiy(in ink)or type.
0 PROPERTYPINFORMATION
INFOMATION
SITE ADDRESS_ '35 O' G7 -\ "�� S V I SUITE/UNIT#_(MO\
ASSESSOR'S TAX/PARCEL# 2 `F' 0 0 - v O v LOT SIZE(sj)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal descnption)
I. PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed descrOtion I work included on this permit only)
1
PROJECT NAME(Nctme of Business or Owner Last Name) ik, . °1/i 6,
,
• PEOPLE INFORMATION
PROPERTY NAME �/A /'1�' r PRIMADY PHO �l/ f�('.� / \ p
OWNER . S `Y`��V" (A I \C�'M t\N (�S)1 .(A‘"\S.- v v
MAILING S 1� ITY,STAT P E-MAIL ADDRESS
CONTRACTORop,COM Er _A \ L�..lAPPC\>\IIIN IEQD. ) �j
VeitFt.� NG A'CRESS. CITY,ST TE,ZIP O ' 3�J
mmt 0,4
R t\ ���?\ CITY OF EDEn�R/�IY�USINES�ENS NUMBER� EXPIRATION DATE ����I�F,_/+ ��
lJ g CONTRACTORS REGISTRATION NU B EXPIRATION DAT E-MAIL ADDRESS
COPY tend ragWrad , r>: c4 CO-C\ JS . \ �4-O T
with oath applleatlon `,/
APPLICANT COMPANY NAME‘
C_ % _APPLIOANT ME OFFICE PHONE
,
AMAILING ADDRESS ) CITY,STATE IP CELL PHONE
J ( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant 0 Agent 0 Other ( ) - C.
PROJECT NAME �, E-MAIL ADDRESS SCJ. ��'`�,' r.,,�CONTACT C.``F^'z\ \V RIMA CE 1� -� t\C :`J .
LENDER NAME <:� Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
m DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ Uwe
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE ❑ TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
AREA DESCRIPTION EXISTING PROPOSED TOTAL
• SQ.FT. 0 SQ. FT. SQ. FT. 1
BASEMENT
FIRST
SECOND
THIRD • .
•
•
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR 0 UNCOVERED?) •
•
GARAGE 0 CARPORT 0
}
NUMBER OF FLOORS =ram PROPOSED TOTAL TOTAL EZ/871N0 Sl TOTAL PROPOSED Sr TOTAL Sl
•
"NEW HOMES ONLY"" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $ I
■ 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 OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION) 1
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS. FANS GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(commercial)
COMPRESSORS FURNACES �- RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING i
BATHTUBS lorYub/Shower Combo) LAVS Bathroom sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS crones
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 Federall 'ay as any claim(including costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claim),which may be in •e by a y person,including the undersigned, and filed against the City of Federal Way,but only where such claim
arises out of the reliance of city i uding its officers and employees, upon the accuracy of the information s ppl d to the city as a part of
this application.
•
NAME/TITLE (6 \I � \ t"\� DATE
(•gnat re) (Title)
RELATIONSHIP TO PROJ CT Owner 0 AgentContractor 0 Architect 0 Other
•
o NEW o ADDITION a ALTERATION o REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO. BASIC PLAN? , ' o YES n NO
ZONING DESIGNATION CHANGE OF USE? a.YES a NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES a NO
PLATTED LOT? o YES 'o NO , DEMO PERMIT REQUIRED? ci YES o NO
Bulletin#100—April 2,2007 . Page 2 of4 k\Handouts\Permit Application •