11-102375 • •
4 :.r !_,,A RECEIVED I ! - L .3_7,5--
Federal Way LIN 15 2011 PERMITSF MF CO ME EL PL DE EN G�!r/
�
COMMUNITY DEVELOPMENT SERVIC
33325AVE
SOU771•PO BOX 9718
55-2607EFAX 25259-835 s Y OF FADER PLI CATION 'U
FEDERAL WAY,WA 98063-9 / /
www.cittwffederalwau•com c DS
The following is required information-an incomplete application will not be accepted. Please print legibly(in ink)or type.
• PROPERTYROOP� INFORMATION
SITE ADDRESS .5Z 12 &Z.)1) E `5 SUITE/UNIT# 0160
ASSESSOR'S TAX/PARCEL# 2 ( 6-4 & 5*- ® e, LOT SIZE(s,9
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
IN PROJECT INFORMATION
.TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING lir FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION( ov detailed description4voork luded on this permit on
'a tEN)EA ' l rve �,+Ew wu-4.4 U
(
PROJECT NAME(Name of Business or Owner Last Name) al> Mee CeieZ05.-Ak.
• PEOPLE INFORMATION
PROPERTY N / D � ( Z)PWARY HOLD-V I -
OWNER %% R�AF}A�SKO�+/- -�) //'� y /{Y /�Y ZIP 1 II f �L� '4
MAILgI l +✓CI.EYVL WAY rte-, rtiziL=VVE E-MAIL ADDRESS
CONTRACTOR C MGGPJ. NAME CANT NAMT>i., O CE PHO E
May C� ?�C�O AlrYC �1ex.4k)A�7J7- oF4 c5/ )€ -
t"G 1 WST ,ZIP CELL E
C�C'FJ goth Let�taik teR (. ..6)n) 1*✓ -' &
C14T-ft-
/ F47 ERALWAY BUSINESS 000a21—W LICENSE��MBAR Il f?1-• loll (42s) .rY77
VA-
C C�}T'OR�'8 REGISTRATION NUMBER EXPIRATION DATE E-MAIL ADDF��i.-`+YI/iaN{
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
( ) -
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
❑SOArrchitect ^- ij❑Tenant ❑Agent 0 Other ( ) -
PROJECT N P Y PHWE E-MAIL ADDRESS
CONTACT 11 I l r (4 4� -
LENDER NAME Per RCW 19.27.095:
Lender information is required If project value exceeds$5,000
MAILING ADDRESS CITY,STATE.ZIP PHONE
( ) -
• DETAILED BUILDING INFORMATION
EXISTING USE C, CE- PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE$ -,-VALUE OF PROPOSED WORK $ Tet
SPRINKLERED BUILDING? %YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
i •
• PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. Q.FT.
BASEMENT
FIRST
SECOND 4727 4 7 ..7
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(0 COVERED OR 0 UNCOVERED?)
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
• 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 GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(Commercial)
COMPRESSORS FURNACES RANGES
DUCTS GAS LOG SETS REFRIG.SYSI'r.MS
PLUMBING
BATHTUBS(orlub/Shower Combo) LAVS Bathroom smka) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS tTotkt)
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 application.
SIGNATURE: t Ch.- 1 e DATE 47- —ii
Property Owner and/or Authorized Agent
FOR OFFICE VSE ONLY
o NEW o ADDITION o ALTERATION o REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? ❑YES o NO
ZONING DESIGNATION CHANGE OF USE? o YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#100—January 1,2009 Page 2 of 4 k\Handouts\Permit Application