09-101815 CITY ORF' Vr- • • - f/ a / F- J. .
Federal Way ,.'---T IT `D51q�
PERM SF MF CO ME EL PL DE EN FP
COMMUNITY DEVELOPMBNTSERVICES
33325 8111 AVENUE SOUTH.PoBOX 9718
FEDERAL WAY,WA 98063-9718 009
APPLICATION
TD / /
253-835-2607•FAX 253-835-2609
u.mw. hro rOlw Com
Y r„ OERAiL WAY
The following is regu ,vv t tformation-an incomplete application will not be accepted. Please print legibly(in ink)or type.
� • PROPERTY INFORMATION
SITE ADDRESS 9,. --' 5 ,!
(� .a74r I S ✓ SC' SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# , 5- Z t 03 - 9 D 6 l LOT SIZE(s)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) )) t`' p>i 1?'/' f—
gEPagera
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 61 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlu)
vl 0,Aj l f— 3 4 0 )---i'1-r, $�ppor-c 11 il VI/�O'1 ---rt., k ri 0
PROJECT NAME(Name of Business or Owner Last Name) hi ey kir 'J v r`4:'---.
:'- if
II PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER ( )
MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
L/C k 1 eX+ �al F ,11 k 5(,��;S1 (2$ )e 2-9.6C-
MAILING ADDRESS �J CITY,STATE,ZIP CELL PHONE
4 01CITY OF...,,---„/;,6
AL WAYBUSINESS LICENSE NUMBER k.,-1 1 4 EXPIRATION DATE 2....._ FAX NUMBER
� --. 2-Y5��
4/ ( ) -
CONTRACTOR'S REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDRESS
j-. -- -'4;'''= er n A-rf 2A-6'. .--,, l,) 0'7'
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
( ) -
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant ❑Agent 0 Other ( )
PROJECT NAME_^ PRIMARY PHONE E-MAIL ADDRESS
CONTACT ) - I'l _ f,, c C;, (.) �) 729 -:Z y--
LENDER NAME 1 Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
/-1/V-1..:5--J--=- I u.J/ 1r -'1/)- U 'hf' rord '*-- ( )
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE$ VALUE OF PROPOSED WORK $ , A, V,.. '
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
: . �'; PROJECT FLOOR AREAS:
AREA DESCRIPTION EXISTING PROPOSED TOTAL
BASEMENT SQ.FT. SQ. FT. SQ.FT.
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS =STENO PROPOS® TOTAL TOTAL WSTINO Sr TOTAL PROPOSED Sr
TOTAL Sr •
"NEW HOMES ONLY$* NUMBER OF BEDROOMS
] FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work$ (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS FANS GA3 WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(commereiaq
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSTEMS
PLUMBING
BATHTUBS(or Tub/shower Combo( LAVS(Bathroom S URINALS
MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS
roue)
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 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, 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
SIGNATURE: �( -•7i
DATE i 70"-O/(�
Property Owner and/or Authorized Agent
3J5 x",' ff
a NEW ❑ADDITION a ALTERATION a REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES a NO BASIC PLAN? a YES o NO
ZONING DESIGNATION CHANGE OF USE? a YES a NO
NEW ADDRESS REQUIRED? o YES a NO UP/SEPA/SU? a YES a NO
PLATTED LOT? a YES a NO DEMO PERMIT REQUIRED? a YES a NO
Bulletin#100—January 1,2009 Page 2 of 4 lalandouts\Pelmit Application