09-104771 .1` • S� - L 72/
CITY DF � RECEAv&:.
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Feder �way PERMIT
COMMUNITY DEVELOPMENT SERVICES rj �O(p SF MF CO ME EL PL DE E FP
33325 8T"AVENUE SOUTH•PO BOX 9718 w V t
FEDERAL WAY,WA 98063-9718 APPLICATION- ,Jscue° /
253-835-2607•FAX 253-835-2609
www.ettyo!Jederalway.conCITY OF FEhDERA �r
The following is required infisl''i Catidt@.Stth)in.Complfteyapplication will not be accepted. Please print legibly(in ink)or type.
• PROPERTY INFORMATION
. y,
SITE ADDRESS /413 C b 0171 - SUITE/UNIT #_
ASSESSOR'S TAX/PARCEL# 7 r -
LOT SIZE (sf) At 7/ 740
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1) sc A 7-r4ei/E)
(Attach separate page for lengthy tegal description)
■ PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
F2,e 5Y5re-MS W63 i AS ADb iA/6 ANl)log /fez xx 9ru v SekiNvc6x //Ei'LS
T /lea)A1MohAt rite Nett/ TENAwr WCL, Ceiu vq, L/6trr,NI, Ayv.
HVAC t 4yvc.i T. A�-L WO ilk LOi LL Be bi9A/C IN iTHOUT A,c-PE2T/.Nq nee
CA PAP Lir' of Tr#E Eris:/V4 S/sTENI .
PROJECT NAME(Name of Business or Owner Last Name) C// 4KClH OF gIE55/A (iS
• PEOPLE INFORMATION
PROPERTY NAME
1�� '/ PRIMARY PHONE
el
OWNER agC// ar 1J -' . S/4'C (, 553)`RLI - 1 273
MAILING ADDRESS CITY,STATE,ZIP E-MAIL ADDRESS
/4/3 0 S 330 rrr 57 Fe7x72.41 co+Y, W4 98
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Fat- 5'yirEMs Wesr lvc SAME (o'53)V33 - 09E'
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
a/5 /g1 , 4( tfb Al. Sit 8 AtortcWA- 9805'7 ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
/� -?-7 - 0606 I bo - BL-- / �l1a 7 ( ) -
CONTRACTOR'S REGISTRATION NUMBER EXPI TION ATE E-MAIL ADDRESS
COPY of card required
with each application I r/R Cs� i (9 b /9//Y// A-
APPLICANT COMPANY NAME NT NAME (` OFFICE PHONE
Fi cE'5YsTCMS 4t)EST //VC SAME (0963 )S33 - /62Ve
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
all C3 FAoNr4Sf RD N 5re.6 il ,F/c- , 1, 24 9ro4/7 ( ) -
RELATIONSHIP TO PROJECT �1�� FAX NUMBER
❑ Architect 0 Tenant ❑Agent O ��
ther r`�O,,vTQACTbk ( ) -
PROJECT NAME PRIMARY PHONE E-MAIL ADDRESS
CONTACT 4" TAO: (J63 ) S'33 - la tit
LENDER NAME Per RCW 19.27.095:
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY.STATE,ZIP PHONE
( )
• DETAILED BUILDING INFORMATION /��
EXISTING USE efltAlCH PROPOSED USE (, 74,/ge
EXISTING ASSESSED/APPRAISED VALUE$ I,.?/3�'ISO() VALUE OF PROPOSED WORK $ /3 60o
SPRINKLERED BUILDING? A YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? j'YES 0 NO
WATER SERVICE PROVIDER X LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER %7 LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
• PROJECT FLOOR AREAS
AREA DESCRIP_ N EXISTING PROPOSED TOTAL
SQ. FT. SQ.FT. SQ. FT.
BASEMENT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑COVERED OR ❑UNCOVERED?)
GARAGE ❑ CARPORT ❑
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 offixture 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
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(Too
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS
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.
i
NAME/TITLE / /ICS Sye /744' DATE /;21 G7;//
(Signature) (Title)
RELATIONSHIP TO PROJECT 0 Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
❑NEW ❑ADDITION n ALTERATION o REPAIR n TENANT IMPROVEMENT
BUILDING SHELL ONLY? c YES ❑NO BASIC PLAN? ❑YES ❑NO
ZONING DESIGNATION CHANGE OF USE? ❑YES o NO
NEW ADDRESS REQUIRED? ❑YES o NO UP/SEPA/SU? o YES ❑NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES ❑NO
Bulletin#100—April 2,2007 Page 2 of 4 k\Handouts\Permit Application