06-100567Pi
RECEIV� � -1- Q 0 �ederal WayPERMIT
COMMUNITY DEVELOPMENT SERVICES rGD O 6 2006 SF MF CO ME EL PL DE EN
33325 8t" AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, WA 98063-9718 TO
253-835-2607• FAX 253-835.2609 R4J'AP L I C AT I O N.-
tuww.ci�Uederalway.cont CITY OF FEDE
BUILDING DEPT.
The following is required information -an incomplete application will not be accepted. Please print lecibly tin i..
SITE ADDRESS �cnS n - ZS"- SW SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # Q 1 Z Uri 3 - c\ \ ( LOT SIZE (sf a% C17- s�
i 1 1 L
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) �� a
(Attach separate page for lengthy legal description)
PROJWT INFOMATION
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)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME {� PRIMARY PHONE
17�oc�cY�.nnc�S�eX �•-`S�C�e�<e�.,� ( z6a1SS1s-
MAILING ADDRESS CITY, STATE, ZIP
9 4 r-1 4'x -0.-V- Ave SCJ S & R7 ",7-C
COMPANY NAME
NAME
OFFICE PHONE
APPLICANT NAME
OFFICE P;iONE
�.►Ju�
��re
�c'c�ec
��1�is
ILS) S(�S7
MAILING ADDRESS
❑ Architect ❑ Tenant ❑ Agent 94 Other (Describe)
CITY, STATE, ZIP
WC
CELL PHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
t 9,- a I_
- o 0 o
c <-_— •7- - B L t om/ 3 i / o
(4z5- ) -48; - St, 7
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application)
EXPIRATION DATE
A D Y A
COMPANY NAMEAPPLICANT
NAME
OFFICE PHONE
`\
10 01Q Q -
MAILING ADDRESS
CITY, STATE, ZIP —
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent 94 Other (Describe)
EXISTING ASSESSED/APPRAISED VALUE $
PROPOSED USE
VALUE OF PROPOSED WORK $ /0 QQ(:)
SPRINKLERED BUILDING? YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? AYES �❑ NO
WATER SERVICE PROVIDER ALAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE (SEPTICI
AREA DESCRIPTION
EXISTING
SQ. FT.
PROPOSED
SQ. FT.
TOTAL
SQ. FT.
BAS NT
SUMPS
WASHING MACHINES
URINALS
FIRST
VACUUM BREAKERS
SECOND
THIRD
FOURTH
E
ADDITIONAL FLOORS (DESCRI
DECK(COVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
CXI5TIN0
r POSED
TOTAL
,� 70TAL LXIsinfo6
a
�?, ,w,
i rOiAL PROP09Cn 9r' ,y
'}-+c ,u. pr.
N ,
*•NEWHOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fi <tureA be installed or
Value of Mechanical Work
AIR HANDLING UNITS EVAPORATIVE COOLERS
BBQS FANS
BOILERS FIREPLACE INSERTS
COMPRESSOR FURNACES
DUCTS GAS PIPE OUTLETS
PLUMBING
BA TUBS (or Tub/Sha rCombo)
SHOWERS
HWASHERS
SINKS
GAS PIPE OUTLETS
SUMPS
WASHING MACHINES
URINALS
LAVS inau.room
VACUUM BREAKERS
as part of this project. Do not include existing fixtures to remain.
LOGS
RANGES N
GAS WATER
WATER CLOSETS Roakq
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
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. _ 'el ^
NAME/TITLE
(Signature) Q
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent
❑ Contractor ❑ Architect
— DATE Z/�v�0 10
❑ Other_ 'ielY. r"'_
Bulletin #100 —January 7, 2005 Page 2 of 4 k\Handouts\Pennit Application