04-103117 COMMUNITY DEVELOP SERV
CEIVED ICES
N i 33530 FIRST WAY SOUTH•PO BOX 9718
`/r" LOPMENT •;;MIT APPLICATION Fr FEDERAL WAY,WA 98061-418
Federal r 253-6614115•FAX:253-661-4129
O tu[uw.cityoQederalway.mm
406 5
For OSko Use Only
FW File Number: Q 4 — 1 /�1\L) -II a / f 1^ — 0 0 TD:
i 1
The ollourin• is re.uired in ormation—an incom.lete a.•lication will not be acce'ted. Please •rint le•ibl (in ink)or •e.
■ PROPERTY INFORMATION
SITE ADDRESS: 192,00.1 ,'m, A e y I 016 SUITE/APT # OV'1- OF
ASSESSOR'S TAX/PARCEL#: X l l0 c - Q b 1 Q SQUAREFOOTAGEOF LOT:
LEGAL DESCRIPTION (e.g.:Acme Estates, Lot 1) 4111111,1 A
,1 1 Vi ppI
1�
(Attach separat page for lengthy legal description)
. • ■ PROJECT INFORMATION
TYPE OF PERMIT(This application): 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION
0 ELECTRICAL 0 ENGINEERING p4tIRE PREVENTION SYSTEM n L`O
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlu): X I viol ol Fl Sp.-I F'In 11 1 a,
-:, ' ctim tb Level
owems M Iv Al' p v-cP- c7pa
ksle1z-
PlzD te-- i iY\ Vl 15pofce of cints-i- tilte f02 e 1 lc fi1�ftCfil4Vl
PROJECT NAME(Name of Business/Owner Last Name): AY V 1 ni 611 i P tnJ
■ PEOPLE INFORMATION
PROPERTY NAME: ,.w�� t PRIMARY PHONE:
OWNER -t
- 5v`> ~D LDrivvv'QN-, cs), ( ) -
MAILING ADDRESS(STREET ADDRESS;): CITY,STATE,ZIP
CONTRACTOR: NAME COMPANY OFFICE PHONE:
c lot Flee P12-4l5ec-iieh as-3) 026 - 7110
MAILING ADDRESS(STREET ADDRESS;): CITY,STATE,/ZIP j ����""//���''/��7//"���'' CELL PHONE:
21 r� 7O f V`)A� His" -Toc�l( q 1 WA Pi
� FAX NUM)ER:
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER:
L` -i _1-1 a 1 .@ - ill i i °LI (ZS3 ) 12. - 6 t cb
v o
CONTRACTOR'S REGISTRATION NUMBER: EXPIRATION DATE:
(copy of card required with each application) 2 /�.g A. f 2 0 9 el C f / /
LENDER NAME: DAYTIME PHONE:
(If Proposed Value>$5,000) ( ) —
MAILING ADDRESS(STREET ADDRESS;): CITY,STATE,ZIP 1
APPLICANT: NAME: a COMPANY OFFICE PHONE:
OW- CPI r,g- P luau* Fre PYl l-cctt r (25" )12b 'lig 0
MAILING ADDRESS(STREET ADDRESS):. CITY,STATE,ZIP EVENING PHONE:
Zi U7 70 f t VIM s- 7a ccm4 ,vYl\ °)Vi 24 ( ) • -
RELATIONSHIP TO PR ECT: FAX NUMBER:
0 Architect 0 Tenant Other(Describe):Ar1k 3-5 ( L C.,„,,---00-0....._(2.g; ) t37,2_, -L I SO
CONTACT PERSON FOR THIS PROJECT: 0 Property Owner ❑ Contractor ®'Applicant E-MAIL ADDRESS:
■ DETAILED BUILDING INFORMATION
EXISTING USE: PROPOSED USE:
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK: $ 14331
SPRINKLERED BUILDING? KYES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED?: WES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
• ■ PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
TOTAL EXISTING TOTAL PROPOSED TOTAL EXISTING AND PROPOSED
HOW MANY FLOORS?
"NEW HOMES ONLY`" NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
■ FIXTURES
Indicate number of each type of fixture that is to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
- RS GAS LOGS REFRIG.SYSTEMS
EVAPORATIVE COOLERS AIR HANDLING UNITS
BBQS FANS HOODS WOODSTOVES
(comm<niall
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
SHOWERS WATER CLOSETS(rode) MISC(Describe)
DISHWASHERS(orTub/snoTub/Shower
SINKS BATHTUBS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYS
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sink VACUUM BREAKERS ELECTRIC WATER HEATERS
■ 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 fled 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.
DATE: e ��
NAME/TITLE:
(Signature( (Title)
RELATIONSHIP TO PROJECT: 0 Property Owner o Applicant ntractor o Architect ❑
FOR OFFICE USE ONLY:
a NEW o ADDITION a ALTERATION a REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES a NO BASIC PLAN? a YES a NO
ZONING DESIGNATION: CHANGE OF USE? a YES a NO
NEW ADDRESS REQUIRED? ❑YES a NO UP/SEPA/SU? a YES a NO
PLATTED LOT? ❑YES a NO DEMO PERMIT REQUIRED? a YES a NO (.
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