07-104452CITY OF
Federal Way R.ECEIVI %PERMIT
COMMUNITY DEVELOPMENT SERVICES SF .FCO ME EL PL DE EN FP
33325 81H AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, WA 98063-9) 718 UG
i O ; APPLICATION T�
253-835-2607• FAX 253-835-260 l7 -- /
unc_ ci(fIcrYerahrnu. com F 1A'
The following isCe � ���TTTCCCiii Utj'1 TWa Al%n incomplete application will not be accepted. Please print legibly (in ink) or type.
PROPERTY
• . •.•
SITE ADDRESS +1� //�/C �(,()S/ �p�s.=j/, SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # LOT SIZE (sf) 3% n- 5
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page far lengthy legal description)
PROJECT• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING "-FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
PROJECT NAME (Name of Business or Owner Last Name) I • t
PROPERTY
OWNER
CONTRACTOR
COPY of card required
with each application L�
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
0 PEOPLE INFORMATION
NAME
rot
w V- c 140
PRIMARY PHONE
(263)831-91,97
MAILING ADDRESS
Z 3 'Tkrrdia SE
'33Z
CITY, STATE, ZIP
w g80 9z
E-MAIL ADDRESS
PHONE
TCFLL
MAILING ADDRESTA EZl
i�, 1I.1' ����/y�j��/�/ 3
HONE -
3 ��- i (q
C•^•��nc cMlfH'.HAI. WAY FfII\'INN'.r\'.'i.if •N��1_1w,. �. 1..-•-•�-�1•..•••1...
FAX IVUIV
`rt
CONTRACTOR'S REGISTRATION NUMBER EXP/ RATION DATE
/lam
E-MAIL ADDRESS
L— kt-1 fi E (.
,C�OMPANY NAME S `O� � �G APPLICANT AME
e -/1X
OFFICE PHONE -
ILING ADDRESS CITY, STATE, ZIP
r�4Z
CELL PHONE
qVt-07 ZFAX
RELATIONSHIP TO PROJECT
NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other
NAXAP
t 1L 1 >,11f �
PRIMARYP"nNE
253 - rior'! / - >
E-MAIL ADDRESS
NAME
Per RCW 19.27.095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED/ APPRAIS
ED $
SPRINKLERED BUILDING? ❑ NO
WATER SERVICE PROVIDER P. LAKEHAVEN
SEWER SERVICE PROVIDER N' LAKEHAVEN
PROPOSED USE �y ^�
_VALUE OF PROPOSED WORK , ;�
FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED? ES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
SQ. FT.
PROPOSED
SQ. FT.
TOTAL
SQ. FT.
BASEMENT
VACUUM BREAKERS
DRINKING FOUNTAINS
SHOWERS
FIRST
ELECTRIC WATER HEATERS
SINKS
WASHING MACHINES
SECOND
SUMPS
ZONING DESIGNATION
THIRD
❑ YES
❑ NO
NEW ADDRESS REQUIRED?
ADDITIONAL FLOORS (DESCRIBE)
UP/SEPA/SU?
o YES
o NO
DECK (❑ COVERED OR ❑ UNCOVERED?)
❑ YES ❑ NO
DEMO PERMIT REQUIRED?
o YES
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL E[ISTDJO Sr
TOTAL PROPOSED Sr
TOTAL SP
""NEW HOMES ONLY'" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be-In4talled or relocated as part of this project. Do not in existing fixtures to remain.
Value of Mechanical Work $ (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLS 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
BATHTUBS (or Tub/Shower Combo)
LAVS (Bathroom Sinks)
URINALS MISC (Describe)
DISHWASHERS
RAINWATER SYST
VACUUM BREAKERS
DRINKING FOUNTAINS
SHOWERS
WATER CLOSETS (rolleq
ELECTRIC WATER HEATERS
SINKS
WASHING MACHINES
HOSE BIBBS
SUMPS
ZONING DESIGNATION
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 �Qcluding its officers and employees, upon the accuracy of the information supplied to the city as a part of
this application. N -01
NAME/TITLE
PROJECT ❑ Owner ❑ Agent
ontractor ❑ Architect ❑
TE 0�-- 19' 07
,aFPk�FICE IJSrEITLY r $
ce
.
❑ NEW ❑ ADDITION
o ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY?
o YES o NO
BASIC PLAN?
❑ YES
o NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
❑ NO
NEW ADDRESS REQUIRED?
o YES ❑ NO
UP/SEPA/SU?
o YES
o NO
PLATTED LOT?
❑ YES ❑ NO
DEMO PERMIT REQUIRED?
o YES
o NO
Bulletin #100—April 2, 2007 Page 2 of k\Handouts\Permit Application