07-101880CITY a
Federal Way F�� � ' ' • .� .Q � �..� -
COMb1UmTY DEVELOPMENT SERVICES
x�o� PERMIT &)MF CO ME EL PL DE EN FP
333?wtuu�.tyltnrf(SeA9miwau.mm7�9�7 M� FEDERAL WAYW8063-918
TO
.153.835-2607• FAX 253..83S-2609 AWLICATIONgg
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The following is requ ormation - an incomplete application will not be accepted. Please print legibly (in ink) or. type.
SITE ADDRESS Ir LSI-__CidY�bT�'c. C:.i L7Ga 1 SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # �� ` � LOT SIZE (s•)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) _ r✓ L
(Attach separate page ICY Isga! dasarfpHon)
PROJECT INFOMIATION
TYPE OF PERMIT R BUILDING .13 PLUMBING ❑ MECHANICAL
❑ DEMOLITION O ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTIO vide tailed description of work included .on this permit only)
PROJECT NAME.(�Vame of Busines or Owner Last Na g)
In
N PEOPLE INFORMATION
PROPERTY
OWNER
CONTRACTOR
COPY of ewd ngdnd
with eeeh uppumuen
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
L W%b.; � 40
NAME
/PRIMARY PHONE
MAILINGADDRESS
S
CITY, STATE, ZIP
E-MAIL ADDRESS
1199" .,.
EAoJM65
b
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
- �o
MAILING ADDRESS,STATE,
Z
''
CELL PHONE
b
MAILING ADDRESS,
STATE, P
CELL PHONE
-aa
REIATION19HIPTO PROJECT
FAX NUMBER
o Architect o Tenant o Agent o Other
CITY OF FEDERAL WAY BUSINESS LICEN NUMBER EXPIRATION DATE
FAX NUMBER
a066 056-53
CONTRACTORS REGISTRATION NUMBER EXPIRATION DATE
E-MAILADDRESS
-' 96
COMPANY NAME 1
APPLICANT N
,O�FFI�CEE PHONE
l -y► ss+ }
- �o
MAILING ADDRESS,STATE,
Z
''
CELL PHONE
b
W
-aa
REIATION19HIPTO PROJECT
FAX NUMBER
o Architect o Tenant o Agent o Other
(
b
NAME PRIMARY PHONE E-MAIL ADDRESS
a il--mac 0 Y e6.
NAME
P1r RCW 19.27.095:
Lender information is required {%project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
b
PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $_ VALUE OF PROPOSED WORK $(_(W)u
SPRINKLERED BUILDING? o YES VO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES o NO
WATER SERVICE PROVIDER=HAVEll
HAVEN ❑ HIGHLINE p TACOMA o PRIVATE (WELL)
SEWER SERVICE PROVIDER o HIGHLINE ❑ PRIVATE (SEPTIC)
4
AREA DESCIWION
EXISTI
S . FT:
PROPOSED TOTAL,
SQ. FT. $ : FT.
BASEMENT
BUILDING SHELL ONLY?
o YES o NO
FIRST
DYES
o NO
SECOND
CHANGE OF USE?
THIRD
o NO
NEW ADDRESS IMQUIRED?
ADDITIONAL FLOORS (DESCRIBE)
UP/$EPA/SU?
o YES
DECK COVERED OR O UNCOVERED?)
PLATTED LOT?
a YES o NO
GARAGE CARPORT 0'
o YES
4�
NUMBER OF FLOORS
swaTls6
AROPOaED
TOTAL
TOTAL EAaTDOU ar
TVTAL PROPOSED ar TOTAL ar
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fxture to be installed or relocated as part of this project. Do. not include existing fixtures to remain.
MECHAMCAL _
Value of Mechanical Work $ -3-3/710 IL 1A COP 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 HOO138 (commerdeq
COMPRESSORS FURNACES �_ RANGES
DI CTsi GAS Lbd SETS • REFRIG. SYSTEMS
PLUMBING
BATHTUBS (or Tub/shewerCombo) LAVS 19athroomSinke) URINALS MISC (Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS / SHOWERS _ 5 WATER CLOSETS (Toueq
ELECTRIC WATER HEATERS �_ SINKS WASHING MACHINES
HOSE BIBBS SUMPS
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 authorised 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 flied against the City of Federal Way, but only where such claim
arises out of the reliance of the city, inclng its officers and employees, upon the accuracy of the'f formation supplied to the city as a part of
this application. _ f n 7t_____)
NAME/TITLE DATE �V
at Mdel
RELATIONSHIPTO PRO ❑ Owner O Agent 0 Contractor ❑ Architect A4 bther
o NEW a ADDITION
o ALTERATION
a REPAIR o TENANT IMPROVEMENT.
BUILDING SHELL ONLY?
o YES o NO
BASIC PLAN?
DYES
o NO
ZONING DESIGNATION
CHANGE OF USE?
o YES
o NO
NEW ADDRESS IMQUIRED?
o YES o'NO
UP/$EPA/SU?
o YES
o NO
PLATTED LOT?
a YES o NO
DEMO PERMIT REQUIRED?
o YES
o NO
Bulletin #100 -January 1, 2007
Page 2 of 4
andouts\Permit Application .