09-102578 REC VED
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Federal way r RIT
COMMUNITY DEVELOPMENT SERVICES R , SF MF CO ME EL PL DE EN,
33325 STM AVENUE SOUTH•POB 7 �� �, - ��A1Y1TI O N
FEDERAL WAY.WA 98063-9 �� ate, n /
253-835-2607•FAX OM
wirw.citu��li�•dcralway n(uray.com
The following is required information-an incomplete application will not be accepted. Please print legibly(in ink)or type.
• PROPERTY INFORMATION
SITE ADDRESS 3 705 r'fi Ave
, 8 S»c� 3 U•(,l l C 8 SUITE/UNIT#
9 / L
/ _
ASSESSOR'S TAX/PARCEL# 2 , G - 0 / CD LOT SIZE(sj)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page fir lengthy legal description
MI PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION X ELECTRICAL 0 ENGINEERING xr FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onl>1)
Law Uc'i ILS f a 4,:r. ,464/2.".
-1-A'Srail Cv^4Tito L. ?AnL 5,440Ka5, ?di iSi Aa id lift ,4udi0 iii 5uAL_ gra)
PROJECT NAME(Name of Business or Owner Last Name) U S.. C( ,v Su S 301-€-A'iA V
R PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER ( ) -
MAILING ADDRESS CITY.STATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
1( /a(6rAA/ c6Cv,z.i 7 6A/C 5,-am Ais0J (ZS3 )6 3f3 -/7F1
MAILING ADD S CITY,STATE,ZIP CELL PHONE
(�(-)• l x. 71
7f 7I
Ke-Aire e L A _ 980'y z. ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
W-040 - 1006-5-00- 3L 12131 /09 (Z:S) ) (0S8 - 0.s
94.
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
MER-/6 Se 0 ZZ 65 031 Z.00i0
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
M 6,2l 6(A).. SC-sC c.> I`-7 DPvcf: sre 150.E (ZS3) 6 38 - /75z
MAILING ADDRESS CITY.STATE,ZIPCELL PHONE
0 y, 7171 gee- WA •9'&'°4'Z. ( ) -
RELATIONSHIP TO PROJECTFAX NUMBER
0 Architect 0 Tenant o Agent V Other COI/1/14 C Tbz. (2s3 ) 638 - 0 396
PROJECT NAME PRIMARY PHONE E-MAIL ADDRESS
CONTACT ( ) -
LENDER NAME Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE.ZIP PHONE
( )
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE ��jj�.��y�
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ (e5e.:X) —
SPRINKLERED BUILDING? 0 YES IKNO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN o HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER o LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
II PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
EXISTING I PROPOSED I TOTAL
TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
NUMBER OF FLOORS Il
**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 COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATIO
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 URINALS MISC(Describe)
BATHTUBS(or Tub/Shower Combo) LAVS(Bathroom Sinks)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSE IS(Toilet)
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 h' ess the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in the
investigation a ' defense of suc( claim), which may be made by any person, including the undersigned, and filed ag against
the
city, bated to
only
where such cf.je a A out of t 1 reliance of the city,including its officers and employees, upon the accuracy of the
on
the city as a p,� of t pplica
DATE 7.- v - GE�J�
SIGNATURE:
I Property Owner and/or Authorized Agent
1
"io�� 4a �§
o NEW o ADDITION o ALTERATION o REPAIR o TENANT IMPROVEMENT
❑YES ❑NO
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? ,-„
ZONING DESIGNATION CHANGE OF USE? sw o YES
o NO
P/SEPA/SU? o YES o NO
NEW ADDRESS REQUIRED? o YES o NOUP/SEPA/SU?
P o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED?
Bulletin#100-January 1,2009
Page 2 of 4 k\Handouts\Permit Application