03-104677CONSTR PER APPLICATION
CITY 4% RECEIVED
OF �+� OCT�3 ZO�3 PPLICATION NUMBE • -
FederalWay R• � fl_
OI-fY OF FEDERAL `NAY APPLICATION NUMBER:
BUILDING DEFT_ PPLICATIOI NUMBER:-
-The following is required information - Please print (in ink) or type"
SITE ADDRESS: 'I OZ 3W PL S (Curt, G4ASSESSOR'S TAX/PARCEL #: •3� D J 8� - Q V � O
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
'AlPitOJECTINFORMA770N
TYPE OF PROJECT (This application): o BUILDING o PLUMBING MECHANICAL o DEMOLITION
o ELECTRICAL o E1NGINEERING """o��� FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description): /NS/ �e ����� �Z -5lqvqv
it y
PROJECT NAME:
PROPERTY OWNER: j NAME`
MAILING ADDRESS (STREET ADDRESS; CITY, $TATE, ZIP): '
CONTRACTOR:
DAYTIME PHONE;
NAME:
i DAYTIME PHONE: ;
MAILING0 ESS (ST
1 ECRESS; , STATEZIP),
q Pi
j VPHONE'
JY) �26 /. D 395 !
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER:
FAX NUMBER:
CONTRACTORS REGISTRATION NUMBER:
I EXPIRATION DATE:
(copy of card required)
— — — — — i / I
APPLICANT: NAME:
/ ILI(NG ADDRE (STREET
EET ADDRESS; CITY, STATE, �IG)J�� �z � L%A
/1
RELATIONSHIP TOPRO)ECT:
❑ ARCHITECT ❑ TENANT ❑ OTHER ( DESCRIBE):
CONTACT PERSON FOR THIS PROJECT: o
EXISTING USE:
PROPOSED USE:
SPRINKLERED BUILDING?
WATER SERVICE PROVIDER:
SEWER SERVICE PROVIDER:
) 26 l -�B1�s
EVENING PHONE:
FAX NUMBER:
E-MAIL ADDRESS:
I
TY OWNER [i APPLICANT u CONTRACTOR I
EXISTING BUILDING ASSESSED/ APPRAISED VALUATION ; zz
PROPOSED VALUATION FOR IMPROVEMENTS: ; 1�
o YES U NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: o YES ❑ NO
o LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ LAKEHAVEN o HIGHLINE C PRIVATE (SEPTIC)
**NEW RESIDENTIAL CONSTRUCTION ON
NUMBER OP BEDROOMS: r ESTIMATED SELLING PRICE: $ /
FLOOR
EXISTING SQ. FT.
PROPOSED S
TOTAL
BASE T
FIRST
SECOND
4
THIRD
FOURTH
OTHER FLOORS (DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
r_ TOTAL:
COMPfg
DUCT(S)
BATHTUB(S)
DISHWASHERS)
DRINKING FOUNTAIN(S)
GAS PIPE OUTLET(S)
INTERCEPTORS)
Indicate number of each type of fixture
Ib1X41:L•Vt(Gr14
RATWE COOLER(S)
FIWEPLACE INSERTS)
FURNACE(S)
GAS PIPE OUTLETS)
PLUMBING
LAVATORY(S)
RAIN WATER SYS.
SHOWER(S)
SINK(S)
SgMP(S)
GAS LOG(S) REFRIG. SYSTEM(S)
HOOD(S) WOODSTOVE(S)
RANGE(S) MISc. ( )
HEAT SOURCE: ❑ ELECTRIC ❑ GAS
URINAL(S) WATER HEATER(S)
VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
WASH MACHINE OUTLET
WATER CLOSET(S) MISC. ( )
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 pen -nit 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. 7
NAME/TITLE: f�j/' t -r DATE: / /� /C� 3
❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
FOROFFICE,USEONLY: °>
COMMUNFfY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063-9718 • 253-661-4000 • FAX: 253-661-4129
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