07-102178 CITY OF.. �-- RECEIVE . 7 - ! 0 •?- t_.,®? 3
Federal Way PERMIT
COMMUNITY DEVELOPMENT SERVIC ] SF MF CO ME EL PL DE EN
33325 8TH AVENUE FEDERAL WAY, 98063-9718 B9rf PR 2 3 200 P P L I C AT I O N TD
.253-835-2607•FAX 253-835-2609 / /
wil.to.efll retieralumli.Oh ?OPp OERA GLWAY
The following is required in ormmation-an incomplete application will not be accepted. Please print legibly(in ink)or type.
• S PROPERTY INFORMATION
SITE ADDRESS 33 5c 7 975 /eii So a r4 SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# 't Z S v 0- (' O Z
_ LOT SIZE(sf)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
. . U PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ;PLUMBING 0 MECHANICAL
❑ DEMOLITION 0 ELECTRICAL 0 ENGINEERING IRE 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) Di' 1)v;4"Ve- ;,7-t''4 -4-4• ,
- •.PEOPLE INFORMATION •
PROPERTY NAME PRIMARY PHONE
OWNER ( ) -
MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANY NAME APPLICANT NAME
- OFFICE PHONE
La,cA/ P/-- G,`'`1 4z,11 _SA.i-K.0 ( r2 ) 32 -4C,Y7
MAILING ADDRESS _ CITY,STATE,ZIP CELL PHONE
roe CoA /`f`I� . y)oic v4ficq b✓R 9 1l;t ('.,4) 39,& - 4,261
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
( yam) //3 -5'46/
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE
COPY of Cord required E-MAIL ADDRESS
with each application I Gc c i pc_c J -2..,..-,0
? '
APPLICANT COMPANY NA�4+E APPLICANT NAME OFFICE PHONE
L.6✓? Trc4 C4-0 r `r -
MAILING ADDRESS CITY,STATE,ZIP - CELL PHONE
RELATIONSHIP TO PROJECT �AX NUMBER
0 Architect 0 Tenant 0 Agent 0 Other ( ) -
PROJECT NAME PRIMARY PHONE
�� � Lv / E-MAIL ADDRESS p
CONTACT 1 ( y��) '142- Fj�: 7ti `�� � � Ce i1lC'ti5-i •'`Yit...[
LENDER NAME Per RCW 19,27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
r _"' ■ DETAILED.:BUILDING INFORMATION
EXISTING USE PROPOSED USE
in
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ j �,'I'"
SPRINKLERED BUILDING? 0 YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN o HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
•
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AREA DESCRIPT ON EXISTING PROPOSED TOTAL
IP SQ.FT. SQ. FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR ❑ UNCOVERED?)
GARAGE 0 CARPORT ❑
EXISTING PROPOSED TOTAL TOTAL EXISTING SP TOTAL PROPOSED ST TOTAL ST
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
• IXTURES
� F
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
DUCTS. GAS LOG SETS REFRIG. SYSTEMS
•
PLUMBING
BATHTUBS(or Tub/Shower Combo) LAVS(Bathroom Sinks) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS ( j; r. .�-S vx I D
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(Tone) . (j T yG
ELECTRIC WATER HEATERS SINKS WASHING MACHINES (b _ Dcr;l� t- tk
HOSE BIBBS SUMPS "7— L Ai•t1\%
• 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 b DATE Y-24/ --00e-7
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner 0 Agent Contractor ❑ Architect ❑ Other
v
ci NEW o ADDITION a ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑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? a YES o NO
Bulletin 4100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application