01-103711 t
6
City of ityFederal Way Building - Single Family Permit #:01 - 103711 - 00 - SF
CommunDevelopment Services
33530 1st Way S
Federal Way,WA 98003-6210
Ph:253 661.4000 Fax:253.661.4129 Inspection request line: 253.835.3050
Project Name: STUBBLEFIELD
Project Address: 30002 2ND PL SW Parcel Number: 720530 0030
Project Description: RES ADD-Remove existing exterior wall,enlarge existing bedrooms(356 sq ft). Includes mechanical
(ductwork); no plumbing.
Owner Applicant Contractor Lender
Philip L&Melissa C Stubblefield BOLDT CONSTRUCTION INC BOLDT CONSTRUCTION INC Philip L&Melissa C Stubblefield
30002 2ND PL SW 21518 127TH PL SE BOLDTCI088PK 1/31/02 30002 2ND PL SW
FEDERAL WAY WA KENT WA 98031 21518 127TH PL SE FEDERAL WAY WA
98023-3569 KENT WA 980311 98023-3569
Includes:
Census category: 434-Reside #1 #2 #3 #4
Occupancy Group: R-3
Construction Type: Type V-N
Occupancy Load:
Floor Area(Sq.Ft.):
1st Floor Proposed Sq.Feet 356 Census Category 434-Residential alt/add-no
Height of Structure 11 Mechanical Yes
Occupancy Group#1 R-3 Plumbing No
Total Building Sq.Feet 2520 Total Proposed Sq.Feet 356
Zoning Designation RS 9.6
•
Mechanical Fixtures
''' „btiOscription 'di l I i Q�.�.�'t MV Desdription,-. ' w .QUantit/ 1' _ :,:1Descnlg$n ,Ara- ',1Q4,160 j'
Ducts 1
?/ ,'d
CONDITIONS:
1.No building shall encroach onto any building setback line or easement shown or not shown.
2.Building setbacks are: 20 feet front; 5 feet side; 5 feet rear.
3.This decision shall not waive compliance with future City of Federal Way codes,policies,or standards relating
to the subject proposal.
PERMIT EXPIRES June 24,2002,IF NO WORK IS STARTED.
Permit issued on December 26,2001
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and the use will be in accordance with the laws,rules and regulations of the State of Washington and
the City of Federal Way.
Owner or agent: 7,7i.-. V)� Date: ,/,..V•,,. ..,`O/
v
r
w - . if
9
INSPECTION LOG
DATE INSPECTOR OK CORR/REJ AREA AND TYPE OF INSPECTION
I
a,
POSOHIS CARD ON THE FRONT Y)F BUILDI `
BUILDING DIVISION
VV FiY INSPECTION RECORD
INSPECTION REQUEST PHONE#: 253-835-3050
PERMIT #: 01-103711-00-SF
OWNER'S NAME: Philip L & Melissa C Stubblefield
SITE ADDRESS: 30002 2ND SW /1/) Oh 0
( ) FOOTINGS/SETBACKS !!/ 4 ) FOUNDATION WALL 1 zJLffJv1
D(? TOT-P QUR CU :;'" p 11P%B0g113 4:1VbVJED` R a
( ) DRAINAGE: Line ( ) Connection
W. ,
OT0:6 �.sf,� Y .... •, ° - :3' Q s Va,.--.
( ) UNDERFLOOR FRAMING I-- *-- )/ 55
O ROUGH PLUMBING: DWV Water piping
( ) ROUGH MECHANICAL ,mow Gas piping �1
( ) SHEATHING / /a £fit `f� �� Roof ///6/Q 2= ` 9Foor
() SHEAR WALLS
() ELECTRICAL ROUGH-IN Ditch Cover
( ) FIRE/DRAFTSTOPS
a •! 7:47.1j'
.m cam ..°2;1
( ) FRAMING/FIRESTOPPING
o , . Valra
HET'
( ) INSULATION: Floors A/4114,235 Walls 4,�1 c.5 Attic 2.//c/€0Z S�
)1L40111,:3 ASTB ew e ® i 15 e '131:07'' - i401474_1:03V411- _
( ) WALLBOARD NAILING 3 11 0 /'d ( ) SUSPENDED CEILING
() ELECTRICAL FINAL
() PLANNING FINAL
() PUBLIC WORKS FINAL
( ) FIRE FINAL
.•r.. .°AElIUSTBEAPPR; Dq iii ° pIK ,044 ! ._ . 2
( ) BUILDING FINAL
O ' " ® m.$ pr x B I1N00 ' `; $ ' ° `"OVN
• 0
c7oxr. CONSTRUC 1 ION PERMIT APPLICATION
kt —"*-----= ECIESKFIL_ ;---. ----- APPLICATION NUMBER: Of --/ 0_3 LI --, F
\>\> Fr Y
A si+ 2 4 rev, APPLICATION NUMBER 1 I — — —- --- — — : — —
**The follqwirkg is.requirpdinc9rmation-Please print(in ink)or type**
'\..
Please note: Electrical,Fire 14:14.reiittilif Sci'attis and Engineering permits may require a separate application.
• • PROPERTY INFORMATION
SITE ADDRESS:30002 .20(/4/L-SW ASSESSOR'S TAX/PARCEL#: 7 :205 .30 - 00_5., 0
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
" ': '. .:','. ' ' - ' .-.' - . ,..- : ' . • , • • PRO3ECT INFORMATION
TYPE OF PROJECT(This application): A BUILDING 0 PLUMBING A MECHANICAL 0 DEMOLITION
0 ELECTRICAL 0 ENGINEERING0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description): iii0EirtVZ E__X S i s 7:e-:.i,ie:C/o/t4 it.4.944./64/1-4,ezE
4-74d6Ys77Afiy 47e_,,a,e ,),/,); ..5'66,izr/
PROJECT NAME: ....57."4/ -?6-1(.&- / / .01' 77/0
• PEOPLE INFORMATION
I ,ERTY OWNER: NAME: DAYTIME PHONE:
# /41/#, 3/404/5;5 5:71/- .Heibfr2740 ( ) -
_
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP):
1-ler-Z0,1‘441,2-5il ,Z0r.Wila 41 Xos
CONTRACTOR: NAME: DAYTIME PHONE:
Z. e:PA 60";,-- 6h 4/e7:- (0.151 ).--/W -/CO 2'1
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): ... ._Aytsfrr7c,er4z,,d 4,./of ccp27,-,4-z EVENING PHONE: ..,
2176,73-9 t.0 .--41,20(1071153.71S hiMig4/**PLIT,(4 ( 4 ) ii -
CM'OF FEDERAL WAY BUSINESS LICENSE NUMBER: FAX NUMBER:
_ - ( ) -
CONTRACTOR'S REGISTRATION NUMBER: EXPIRATION DATE:
(copy of card required) / /
APPLICANT: NAME: / PHONE:
Bie‘-Pr 6645% (Atethate) ;25:,_, ),.*:y
t MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
,141e25.9 /Attie ‘iii/i0oce.,,,,)4(.4 '702-2... ( i, ) te - 1,
t RELATIONSHIP TO PROJECT: - ,
FAX NUMBER:
94:ARCHITECT 0 TENANT 0 OTHER(DESCRIBE):Ag.://t. ( ) -
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: 0 PROPERTY OWNER 0 APPLICANT 0 CONTRACTOR
III DETAILED BUILDING INFORMATION
EXISTING USE: tcf- fa.C2,46'071Z- EXISTING BUILDING ASSESSED/APPRAISED VALUATION $ 7/21,-Ctro, li O(
PROPOSEDGP/
USE:Se - e9t, PROPOSED VALUATION FOR IMPROVEMENTS: $ ?et51-6;429 t-+ /19- ---)
, ( 4-
SPRINKLERED BUILDING? 0 YES xi NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED:0 YES ..121 NO
WATER SERVICE PROVIDER: 0 LAKEHAVEN Al HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER: n LAKEHAVEN jg HIGHLINE 0 PRIVATE(SEPTIC)
**NEW RESIDENTIAL CONSTRUCTION OBEY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $ ii
■ PROTECT FLOOR AREAS
FLOOR EXISTING SQ.FT, PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
!/�B O /0/
SECOND !rJ
THIRD
FOURTH
OTHER FLOORS(DESCRIBE)
DECK
GARAGE `/ r
G�7"
HOW MANY FLOORS? / Jof1"/
TOTAL: a/f� ,, ,5.Z-:. + z>
.. . • ■ FIXTURES-
Indicate number of each type of fixture
MECHANICAL Ei•St'Ll{aQ -- QA�'NA�1 GI
/ AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS LOG(S)(( CCCJJJ REFRIG.SYSTEM(S)
BBQ(S) .i FAN(S) HOOD(S) WOODSTOVE(S)
BOILER(S) / FIREPLACE INSERT(S) RANGE(S) MISC.( )
COMPRESSOR(S) / FURNACE(S)
----X---- DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: 0 ELECTRIC M GAS it
PLUMBING — 6x(9fiig
no
BATHTUB(S) .02- LAVATORY(S) URINAL(S) WATER HEATER(S)
/ DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC At GAS
DRINKING FOUNTAIN(S) „pZ SHOWER(S) ` WASH MACHINE OUTLET
V
/ GAS PIPE OUTLET(S) SINK(S) v2 WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
.. ■. DISCLAIMER/SIGNATURE BLOCK
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 daim(including costs,expenses,and attorneys'fees incurred in the
investigation and defense of such daim),which may be made by any person,induding the undersigned,and filed against the City of
Federal Way,but only where such daim arises out of the reliance of the city,induding its officers and employees,upon the accuracy
of the information supplied to the city as a part of this application.
.` c �" liNAMEJTITLE:
DATE:'
0 PROPERTY OWNER ❑ APPLICANT { CONTRACTOR
FOR OFFICE USE ONLY:,a.
❑'NEW
) :❑ADDITION ❑ALTERATION r.❑�i2EPAIR.- ....,❑::TENANT IMPROVEMENT- `
.CENSUS CODE. ''LOT SIZE :; .........:. ,
YONING_DESIGNATI• N :x BUILDING°SHELL;ONt Y? ..❑YES ❑ NO
COMPi'LAIV DESIGNATION BASIC PLAN?.. .. =❑YES. ❑°NO`
SECTION - TOWNSHIP RANGE IsEW ADDRESS REQUIRED? ❑ YES ❑.NO
PLATTED LOT? „❑YES ❑ NO CHANGE QF USE?;.' ElYES Cl NO
COMMUNITY DEVELOPMENT SERVICES.•33530 FIRST WAY SOUTH•PO BOX 9718•FEDERAL WAY,WA 98063-9718•253-661-4000•FAX:253-661-4129
Contuction Permit Fee Calculationteet
*******PLEASE NOTE: ALL FEES MUST BE VERIFIED BY CITY STAFF PRIOR TO ACCEPTANCE OF PAYMENT.
CHECKS FOR INCORRECT AMOUNTS WILL NOT BE ACCEPTED!*******
Building,mechanical,and fire prevention system fees are based on the following schedule.
TABLE A
TOTAL VALUATION FEE FACTOR
(1)$1.00 to$500.00 (1)$24.25
(2)$501.00 to$2,000.00 (2)$24.25 for the first$500.00 plus$3.27 for each additional$100.00 or fraction thereof,to and including$2,000.00
(3)$2,001.00 to$25,000.00 (3)$71.46 for the first$2,000.00 plus$15.00 kr each additional$1,000.00 or fraction thereof,to and including
$25,000.00
(4)$25,001.00 to$50,000.00 (4)$403.61 for the first$25,000.00 plus$10.82 for each additional$1,000.00 or fraction thereof,to and induding
$50,000.00.
(5)$50,001.00 to$100,000.00 (5)$664.35 for the first$50,000.00 plus$7.50 for each additional$1,000.00 or fraction thereof,to and including
$100,000.00.
(6)$100,001.00 to$500,000.00 (6)$1,025.55 for the first$100,000.00 plus$6.00 for each additional$1,000.00 or fraction thereof,In and including
$500,000.00
(7)$500,001.00 to$1,000,000.00 (7)$3,337.23 for the fist$500,000.00 plus$5.09 for each additional$1,000.00 or fraction thereof,to and including
$1,000,000.00.
(8)$1,000,001.00 and up (8)$5,788.23 for the first$1,000,000.00 plus$3.91 for each additional$1,000.00 or fraction thereof.
Bold number is the base fee for the specified increment
Italicized,underlined number Is the fee per additional specified increment
PLUS: Add 65 percent of the base building permit fee for plan review fee.
Add 25 percent of the base mechanical permit fee for mechanical plan review fee.
Add 15 percent of the base building permit fee for Fire District#39 surcharge,commercial only.
Add$4.50 for WA State Building Code Council,plus$2.00 per unit for duplex&above.
** Electrical,plumbing,and mechanical fees are calculated separately**
_ ■ BUILDING
PROPOSED VALUATION: "10 060r,
FEE FACTOR FROM TABLE A: Number: .3 (a)Base Fee:
(b)Additional Increment Fee: 0270 00
Estimated Permit Fee: (1) _
Estimated Plan Review Fee: (2)
Estimated FW Fire Department Surcharge: (3)
(COMMERCIAL ONLY)
PROPOSED VALUATION: r-4d p46e) 50 c/ �� //
FEE FACTOR FROM TABLE A:Number: (a)Base Fee: +�'511,T//K6
(b)Additional Increment Fee:
Estimated Permit Fee: (4)
Estimated Plan Review Fee: (5)
■ FIRE PREVENTION SYSTEM
PROPOSED VALUATION:
FEE FACTOR FROM TABLE A: Number: (a)Base Fee:
(b)Additional Increment Fee:
Estimated Permit Fee: (6)
Estimated Plan Review Fee: (7)__
■ PLUMBING
Base Fee Number of Fixtures
$21.00+{ X$7.00/fixture}= (8)Estimated Permit Fee
Estimated Permit Fee
X .65= (9)Estimated Plan Review Fee
Miscellaneous Fixture Charge:(10)
Sub Total (Page one): Line(s)(1)+(2)+(3)+(4)+(5)+(6)+(7)+(8)+(9)+(10)= (11)
iiimmmiummum jammumumismaimmi ji6iiimm........
TABLE B `
NEW RESIDENTIAL SERVICES MOBILE HOMES MISC EQUIPMENT/TEMP SERVICES
_Single Family _Service or feeder only $48.00 _#of Thermostats(First-$36.00;add'n-$11.00ea)
(First 1300 ft2-$72.00;Each add'n 500 ftZ-$23.00) _Service and feeder $78.00 #of Low voltage fire or burglar alarms
Square Feet: First 2500 ft2-$42.00;Each add'n 2500 ft2-$11.00
_Each outbuilding or garage $30.00 MOBILE HOME/RV PARK Square Feet:
(Inspected with service) _#of service or feeders *Per WAC 296-46-910(5)(b)(i&ii)
,_Each outbuilding or garage $48.00 (First service/feeder-$48.00;Add'n service/ _#of Signs(First sign-$36.00;add'n sign
(Inspected separately) feeder-$31 each) $17.00 each)
_Swimming pool,hot tub,spa 72.00
_Yard Pole meter loops 48.00
NEW MULTI-FAMILY COMMERCIAL/INDUSTRIAL COMMERCIAL/INDUSTRIAL
(Includes three units or more) Altered Service or Feeders
Service Feeder Amps Service or Add'n _0 to 200 $ 78.00
_Up to 200 amp $ 78.00 $ 23.00 Feeder _201-600 182.00
_201-400 amp 97.00 48.00 _0 to 100 $ 78.00 $ 48.00 _601-1000 274.00
_401-600 amp 133.00 66.00 _101-200 97.00 61.00 _over 1000 305.00
_601-800 amp 170.00 91.00 _201-400 182.00 72.00 _#of circuits
_Over 800 amp 243.00 182.00 _401-600 212.00 85.00 (1-5 circuits-$61.00;Add'n circuits,$5 ea)
ALTERED SINGLE/MULTI FAMILY _601-800 274.00 116.00
(When inspected separately from the services.) _801-1000 335.00 140.00 TEMPORARY SERVICE
Service or Feeder _Over 1000 365.00 195.00 Residential/Multi-Family/Commercial/Industiral
_0 to 200 amp $66.00 _Over 600 volts surcharge 61.00 _0-100 48.00
_201-600 amp 97.00 _Mast or meter repair 66.00 _101-200 61.00
_over 600 amp 146.00 _201-400 -, 72.00
_Mast or meter repair 36.00 _401-600 --- 97.00
_#of circuits _over 600 105.00
(1-4 circuits-$48.00;Add'n circuits$5 ea) __
If service is greater than 200 amp,a plan review is req'd.Fee is 35%of permit fee+$61.00.Add'I plan review for other submissions is$72.00/hr.
MIFIXTURETIESCRIPTION'(A) , , (FIXTURE tFEE;FROM TABL'E B(B)' $M VUMBER OF>UNI S(C) 10-$.%: ,., l'OTAL(D), lr'-v-
ai; --TOTAL COLUMN'(0):
Total Column(D)
Estimated Permit Fee: (12)
Estimated Permit Fee from fine 12
Estimated Plan Review Fee: $56.25+_ X.35=(13)
■ DEMOLITION
Estimated Permit Fee: (14)
Bond Amount:(15)
■ ENGINEERING
Estimated Permit Fee:(16)
Bond Amount: (17) •
■ OTHER FEES
Mitigation Fee: (18) (20) (22)
SBCC Surcharge:(19) (21) (23)
Total(Pages One&Two): Line(s)(11)+(12)+(13)+(14)+(15)+(16)+(17)+(18)+(19)+(20)+(21)+(22)+(23)= (24)
Bulletin#100-August 20,2001
I
POB "O12 -S l'14, 0 14 ,_4
cruor Frte F �,,�' CONS 1 RUCTION PERMIT APPLICATION
VV EI1_
APPLICATION NUMBER: [�f — �� . 1_ _J
SIT 2 4 7G,) APPLICATION NUMBER: _ —
WAY APPLICATION NUMBER: — __ — __ — — —
**The folio }i0qu rel'information-Please print(in ink)or type**
Please note: Electrical, Fire Prevention Systems and Engineering permits may require a separate application.
'.I:PROPERTY INFORMATION
SITE ADDRESS: "Cre :2/✓W/L�SL LI ASSESSOR'S TAX/PARCEL #: 7 9Z 5 ..-j C-' — ( r ., c
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
'..-<,v = ' . ._- A , .:-r`., _ : 1.'PR07ECT INFORMATION
TYPE OF PROJECT(This application): I BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description): � rC, 2- L.X -57 1�-%Lr'/e- ,Ai0,ti-4 /,'",y r,
L �d,57 ,_71/.4 d2:x.;r'CZY/1-2 --'SL / /
PROJECT NAME: `i,/ie.:::: /ELi/ /42,..2/ /L'
. , . r " f , s ■;":PEOPLE INFORMATION
F ROPERTY OWNER: NAME: DAYTIME PHONE:
//7 //, -isiy ',S2/3,94- F27/ 9 ( )
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP):
.Tr1G /1::://4-11.42.2 7 ' /�C ?.�"C .— ''
CONTRACTOR: NAME:
DAYTIME PHONE:
AG d/1/ /4"72t./ii-7--- (,t3-5 )_'7','i1 /C6
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): - - EVENING PHONE:
G Tom- , / ( r. ) r< %e
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: ,r FAX NUMBER:
( )
CONTRACTOR'S REGISTRATION NUMBER: EXPIRATION DATE:
(ropy of card required) / /
APPLICANT: NAME:
DAYTIME PHONE:
if--;7,- .,-;- Li/t,iS -- (Atha/ J\
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
?1`/:'5�/ 51z ,--74.:2 iCt/r-?'�ciV 1/4C e,,, j%' j , 2. ( f, ) re" - l'
'` RELATIONSHIP TO PROJECT: FAX NUMBER:
74 ARCHITECT ❑ TENANT ❑ OTHER(DESCRIBE): / ,'/ ti ( )
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
--::::---,::::'11:,DETAILED BUILDING INFORMATION ' -
EXISTING USE: .5-/-1"---,(1-,,,,4,2-/P7-7-''7Z- EXISTING BUILDING ASSESSED/APPRAISED VALUATION $ le..-1Cri
PROPOSED USE:._ /%,T,/2-,5 �i PROPOSED VALUATION FOR IMPROVEMENTS: $ e'J 63;t
SPRINKLERED BUILDING? ❑ YES RI NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED:❑ YES A NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ,1 HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL) r
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN I HIGHLINE ❑ PRIVATE(SEPTIC) it.,0 ,��`r) VW
r �4�-
Ita
P'S i ✓€ a)Q. t-v+-Ir' 1 ?J
S •
**NEW RESIDENTIAL CONSTRUCTION ONLY** _
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
' ■ PROJECT FLOOR AREAS ..
FLOOR EXISTING SQ.FT, PROPOSED SQ.FT. TOTAL
BASEMENT- /�
FIRST /44 0 _ a0l4.;
SECOND
THIRD
FOURTH
OTHER FLOORS(DESCRIBE)
DECK
GARAGE HOW MANY FLOORS? / <07" l°f 60✓
/
TOTAL: tR`�X ?6Z' a,5
Indicate number of each type of fixture
MECHANICAL EWhini — 410161,61/ AMc k
/ AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS LOG(S) _REFRIG.SYSTEM(S)
.� FAN(S) HOOD(S) WOODSTOVE(S)
BOILER(S)
BBQ(S) / FIREPLACE INSERT(S) RANGE(S) MISC.( )
COMPRESSOR(S) / FURNACE(S)
)_ DUCT(S) / GAS PIPE OUTLET(S) HEAT SOURCE: ❑ ELECTRIC
� M GAS
PLUMBING — V 7filag riaC71���►Ul , _
02 BATHTUB(S) ;•• LAVATORY(S)
URINAL(S) / (WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. l WASHMACHINEACUUBR OUTLET
CI ELECTRIC GAS
DRINKING FOUNTAIN(S) , SHOWER(S)
/ GAS PIPE OUTLET(S) Vp,Z SIN K(S) III- WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
` -11:'DISCLAIMER/SIGNATURE BLOCK
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 jja part of this applicaattiion.,,
NAME/TITLE: /� C11`[ � te"', DATE: 9" '22'0 t
CI PROPERTY OWNER CI APPLICANT ('CONTRACTOR
".FOR OFFICE USE-ONLY ;`
1 NEW M'§,_ ADDITION E.,•''ALTERATIONTIIIEltiffaiiiE0AuemilingElTENANT°IMPROVEMENT
CENSUS:CODE '` ! " "LOT SIZE:'.._ _
ZONING_DESIGNATION,y„ BUILDING SHELLONLY? ❑YES ❑ NO
COMP PLAN DESIGNATION BASIC PLAN? g,-.`❑f.YES',.. ❑ NO'
SECTION,;;. ;TOWNSHIP RANGE NEW,ADDRESS;REQUIRED? ❑ YES - :L,NO
,PLATTED'LOT? •❑YES ❑ NO CHANGE OFUSE?,. , ❑YES ❑ NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH-PO BOX 9718•FEDERAL WAY,WA 98063-9718-253-661-4000•FAX:253-661-4129