06-101330' as
cry OF • I•.�( H EC E+'
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F'ederralWay PERMIT
COMMUNITY DEVELOPRW SERV/ R
999158MAVENUE SOUTH • 63 D71 zoos P P LI C AT I O N
FEDERAL WAY, OU 98069-9718 ,
253-83S-1607-W2S3-1 �6490F FEDERAL
www.dtuo/kdemhimc.mmBUILDING 0)En-s.
The following is required Worma{ibnA-ran incomplete application will not be
SF F CO ME EL PL DE EN FP
MD --
ted. Please print iepibltl lin inkl or tune.
SITE ADDRESS dw
SUITE/UNIT #
aw
ASSESSOR'S TAX/PARCEL # _ - LOT SIZE (sfl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Acach aeparabpoye jer
"• its
e
TYPE OF PERMIT LDING . ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIP�ON (Provide 4etqile�description of work included on this permit only)
PROJECT NAME (Name ofBusinCl Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
NAM CLC PRIMARY
HONE -
MAILING ADDRESS , ^ 9A sc / CITY, STATE IP
/4, +V/1
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDR
CITY, STATE, ZIP
CELL PHONE
CITY OF FEDERAL WAY USINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
ELL PHONE"
Ik0! l
__B L-
CONTRACTOWS REGISTRATION NUMBER (copy of card required with "ch application) EXPIRATION DATE
RELATIONSHIP TO PROJECT
❑ Architect ❑: Tenant
MPANY NAM—z—�
kutk UftwW
APPLICA
AME
��� O�V
0! j
MAIIQP ADDRE33CITY,
�
TE, ZIP
ELL PHONE"
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/
l -
RELATIONSHIP TO PROJECT
❑ Architect ❑: Tenant
❑ Agent A Other
FAX NUMBER
(Describe)
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
'RINKLERED.BUILDING? ❑ YES )(NO FIRE SUPPRESSION SYSTEM PROPOSED%REQUIRED? ❑ YES iQ NO
TER SERVICE PROVIDER �rLAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
t;R SERVICE PROVIDER `g%LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
r
r
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING
SQ.FT.
PROPOSED
SQ.FT.
TOTAL
SQ. FT.
BASEMENT
—I q'T
INJr
__1 K
FIRST
SECOND
THIRD
BBOS
FANS
o YES
FOURTH
\
CHANGE OF USE?
ADDITIONAL FIAORS (DESCRIBE)
o NO
NEW ADDRESS REQUIRED?
BOILERS
DECK (COVERED?) L J _ cv— L, ,
o YES
RANGES
'
GARAGE 9 CARPORT D
FURNACES
o YES
V
NUMBER OF FLOORS
DUCTS
GAS PIPE OUTLETS
G
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of'ftxture to be installed or relocated as part of this project. Do not include existing>ixtures to rernaim
Value of Mechanical Work
I calffly under penalty of perjury that the igformation furnished by me is true and correct to the best of my knowledge, and further. that I
am authorized by the owner 4f the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the City of F deral Way as to any claim (including costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claiW. which may be made by any person, including the undersigned, and ftled against the City of Federal Way, but only where such claim
arises out 4f the reliance of the city, including its QQRoers and employees, upon the accuracy of the Information supplied to the city as a part of
�r
this application
-7k;
NAME/TITLE` DATE
(S4pmture) rnue)
RELATIONSHIP TO PROJECT ❑ er AAgent ❑ C tractor ❑ Architect ❑ Other
FOR OFFICE LIM ONLY
AIR HANDLING UNITS
EVAPORATIVE COOLERS
o REPAIR o TENANT IMPROVEMENIT
GAS LOGS
REFRIG. SYSTEMS
BBOS
FANS
o YES
HOODS (co—ta)
WOODSTOVES
CHANGE OF USE?
—�—
o NO
NEW ADDRESS REQUIRED?
BOILERS
FIREPLACE INSERTS
o YES
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
o YES
GAS WATER HEATERS
DUCTS
GAS PIPE OUTLETS
G
BATHTUBS )or Tub/Shower combo)
SHOWERS
.3
WATER CLOSETS rrou.,)
MISC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPE OU'ILEI'S
SUMPS
RAINWATER SYST
WASHING MACHINES
URINALS
HOSE BIBBS
LAYS )BWh— SIM.)
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I calffly under penalty of perjury that the igformation furnished by me is true and correct to the best of my knowledge, and further. that I
am authorized by the owner 4f the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the City of F deral Way as to any claim (including costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claiW. which may be made by any person, including the undersigned, and ftled against the City of Federal Way, but only where such claim
arises out 4f the reliance of the city, including its QQRoers and employees, upon the accuracy of the Information supplied to the city as a part of
�r
this application
-7k;
NAME/TITLE` DATE
(S4pmture) rnue)
RELATIONSHIP TO PROJECT ❑ er AAgent ❑ C tractor ❑ Architect ❑ Other
FOR OFFICE LIM ONLY
o NEW u ADDITION
o ALTERATION
o REPAIR o TENANT IMPROVEMENIT
BUILDING SHELL ONLY?
❑ YES ❑ NO
BASIC PLAN?
o 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 7, 2005
Page 2 of 4
k\Handouts\Permit Application