04-103212R EC E*E,D
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7l� COMMUNITY DEVELOPMENT SERVICES
Y 1 L U O 33530 FIRST WAY SOUTH • PO BOX 9718
VA�, FEDERAL WAY, WA 98063.9718
CITY of "(TYOF FFD(:PERMIT APPLICATION 253-661-4II5•FAX: 253-661-4129
www. ci tuo((ederalwausom
• 3UILOING f. _
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For OQce Uu Only. FW File Number.
The following is required information - an incomplete application will not be accepted. Please print legibly (in ink) or type,
SITE ADDRESS: I�U n S . 3 Z-0 S ���
ASSESSOR'S TAX/PARCEL #: O - �-7 `, SQUARE FOOTAGE OF LOT:
SUITE/APT#
LEGAL DESCRIPTION (e.g.: Acme Estates, Lot 1)
(Attach separate page for lengthy legal description)
PROJECT•• •
TYPE OF PERMIT (This application): ? BUILDING ? PLUMBING CAL ?;7;7
ON
? ELECTRICAL ? ENGINEERING 9 FIRE PREVENTION
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onitlk li�-t� 0JM L� S JC� I� )�
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PROJECT NAME (Name of Business/Owner Last Name): 1 �1 !�!i �cV� U �j (� n
PEOPLE•• •
PROPERTY
NAME: PRIMARY PHONE:
OWNER: V �
CONTRACTOR:
LENDER:
(If Pr P—d VeV.1—> $5,000)
APPLICANT:
NAME:
ASSESSED/APPRAIS V UE $
SPRINKLERED BUILDING? YES ? NO
DAYTIME PHONE:
MAILING ADDRESS (STREET ADDRESS;):
MAILING ADDRESS (STREET ADDRESS;):
u LI-( o H � � zap
CITY, STATE, ZIP
Log 4t tv qqn,&
SEWER SERVICE PROVIDER: Y L7i�AAVEP
? HIGHLINE ? PRIVATE (SEPTIC)
I AME: COMPANY
NAME
OFFICE PHONE:
Il,^COMPANY
(,
OFFICE PHONE:
EVENING PHONE:
( 1 -
MAILING ADDRESS (STREET ADDRESS;):
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( Y, 1;M lbR19
CITY, STATE, ZIP
CELL PHONE:
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER:
EXPIRATION DATE:
FAX NUMBER:
CONTRACTORS RET-,ISTRATION NUMBER:
(
� � �
EXPIRATION DATE:
I (i 2"
(copy of card required with each grpllcatlou) _
V
n
NAME:
ASSESSED/APPRAIS V UE $
SPRINKLERED BUILDING? YES ? NO
DAYTIME PHONE:
MAILING ADDRESS (STREET ADDRESS;):
CITY, STATE, ZIP
? HIGHLINE ? TACOMA ? PRIVATE (WELL)
SEWER SERVICE PROVIDER: Y L7i�AAVEP
? HIGHLINE ? PRIVATE (SEPTIC)
I AME: COMPANY
OFFICE PHONE:
MAILING ADDRESS ( ADDRESS): CITY, ST TE, ZIP
roti _
Ib`6
EVENING PHONE:
( 1 -
RELATIONSHIP TO PROJECT:c
? Architect ? Tenant ? Other (Describe)::)
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FAX NUMBER:
Y,,Au ) .` i
•EXISTING
ASSESSED/APPRAIS V UE $
SPRINKLERED BUILDING? YES ? NO
VALUE OF PROPOSED WORK: $
FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED?: ? YES ? NO
WATER SERVICE PROVIDER: ??_L�AKEHAVE_N\.
? HIGHLINE ? TACOMA ? PRIVATE (WELL)
SEWER SERVICE PROVIDER: Y L7i�AAVEP
? HIGHLINE ? PRIVATE (SEPTIC)
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•
■ PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING SQ. FT.
PROPOSED SQ. FT.
TOTAL
BASEMENT
? NEW ? ADDITION
? ALTERATION
? REPAIR ? TENANT IIMPROVEMENT
FIRST �i
j
V V
1 ,
?YES ?NO
BASIC PLAN?
? YES
SECOND
ZONING DESIGNATION:
CHANGE OF USE?
THIRD
?NO
NEW ADDRESS REQUIRED?
?YES ?NO
FOURTH
? YES
? NO
PLATTED LOT?
ADDITIONAL FLOORS (DESCRIBE)
DEMO PERMIT REQUIRED?
? YES
? NO
DECK (COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS?
TOTAL EXISTING
TOTALPROPOSED
TOTAL EXISTING AND PROPOSED
"*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 ofMechanical v �� l (�? �7 (J t t ��"� i ( i Y� � � " � (j 1 � �{�'I trt/✓ "' r
Work $ v l
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS for Tub/Shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS Bathroom Sink
EVAPORATIVE COOLERS GAS LOGS REFRIG. SYSTEMS
FANS HOODS )c—nr at) WOODSTOVES
FIREPLACE INSERTS 1/ RANGES MISC (Describe)
FURNACES GAS WATER HEATERS
GAS PIPE OUTLETS
SHOWERS WATER CLOSETS (Toiiet) MISC (Describe)
SINKS DRINKING FOUNTAINS
SUMPS RAINWATER SYS
URINALS HOSE BIBBS
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
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.
NAME/TITLE:
RELATIONSHIP TO PROJECT: ? Property OwnerrApplicant ? Contractor ? Architect ?
FOR OFFICE USE ONLY:
? NEW ? ADDITION
? ALTERATION
? REPAIR ? TENANT IIMPROVEMENT
BUILDING SHELL ONLY?
?YES ?NO
BASIC PLAN?
? YES
?NO
ZONING DESIGNATION:
CHANGE OF USE?
? YES
?NO
NEW ADDRESS REQUIRED?
?YES ?NO
UP/SEPA/SU?
? YES
? NO
PLATTED LOT?
? YES ? NO
DEMO PERMIT REQUIRED?
? YES
? NO
Bulletin #100—January 13, 2004
Page 2 of 4
k:\ -Handouts — Revised\Permit Application