05-103123Federal Way PERMIT
COMMUNPIY DEVELOPMENPSERVICES SF O ME EL PL DE EN FP
33325DRAL WA,SOMH WA9•POBOX 9718 APPLICATION
FEDERAL WAY. FAX
98063-9718
253-835-2607• FAX 2.53-835-2609
upuru,ci 4orfederalu,ag.w
The innisTrenuired in ormation -an into Tete avolication will not be acre ted. Please Tint le 1 (in ink) or type.
PROPERTY•. •
SITE ADDRESSy f S. IA/t.� 3z o �� 4 0 SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # ► 0 _'AS LOT SIZE (sfl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach sap" to pMe for lergthy Leval dee foloN
PROJECT INFORMATION
TYPE OF PERMIT C �� (�� ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit on1i1)
�- 1 WOrL(G �
PROJECT NAME (Name o mess V er Last Name) S l7C ZfbeTq-Tj (.e C[.1tSS Rc�oµs@ Dm'�T
PEOPLE•• •
PROPERTY
OWNER
(CONTRACTOR
APPLICANT
CONTACT
LENDER
NAME PRIMARY PHONE
FGTiEF_f'rL WAY _P013IJL SCa-iOaL-S (253 )915 -SOOD
MAILING ADDRESS � CITY, STATE, ZIP
31/toi-, I F e S L WAY 1, WA 1300
COMPANY NAME
APPLACAN"I' NAME
OFFICE PHONE
vT YCr
CITY, STATE, ZIP
)
MAILING ADDRESS
CITY. STATE. ZIP
CELLPHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION UATE
FAX NUMBER
/
)
_
B L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
COMPANY NAME
e4eEwE --GASA-t,-,,A-Y AjecH .
APPLICANT NAME
13PC--T-r iAAi�.51449c-
OFFICE PHONE
(25'3) `14 -
MAILING ADDRESS
CITY, STATE, ZIP
CELLPHONE
(253 ) 6
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
-
V 5-5) 141 - '51 2ZI
NAME
JGss�- L�c�
PRIMARY PHONE
E
(2s3 ) G8� !cb6
-MAIL ADDRESS
J se (9 G4Z+0 ` rw_
Per RCW 19.27.095: Lender irtformation is
required if project value exceeds $5,000
NAME
MAILING ADDRESS
CITY. STATE. ZIP
EXISTING USE SCN-X'L-
EXISTING ASSESSED/APPRAISED VALUE $
SPRINKLERED BUILDING? ❑ YES *NO
PROPOSED USE
VALUE OF PROPOSED WORK $ (Ob 10 050
FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES )rNO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
.CO tit
0
AREA DESCRIPTION
E33STING
SQ. FT.
PROPOSED
SQ. FT.
TOTAL
SQ. FT.
BASEMENT
EVAPORATIVE COOLERS
BBQS
FANS
FIRST
FIREPLACE INSERTS
1-74Z
3584
SECOND
GAS PIPE OUTLETS
CHANGE OF USE? YES
❑ NO
THIRD
_, YES ❑ NO
UP/SEPA/SU? YES
❑ NO
FOURTH
❑ YES ❑ NO
DEMO PERMIT REQUIRED? YES
❑ NO
ADDITIONAL FLOORS (DESCRIBE)
DECK (COVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXI6'fING
MOPOBW
]YFfAL
TOTAL WMTOG 8F
TOTAL PROPOBFD W
TOTAL 8F
3 5
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fix0ure to be installed or relocated as part of this project. Duo not tnclude existiM futures to remail.
BATHTUBS [o T b/Sh-1C..W
SHOWERS
of Mechanical Work $
SINKS
_ AIR HANDLING UNITS
EVAPORATIVE COOLERS
BBQS
FANS
BOILERS
FIREPLACE INSERTS
COMPRESSORS
FURNACES
DUCTS
GAS PIPE OUTLETS
BATHTUBS [o T b/Sh-1C..W
SHOWERS
DISHWASHERS
SINKS
GAS PIPE OUTLETS
SUMPS
WASHING MACHINES
URINALS
LAVS (Bah— Sinks)
VACUUM BREAKERS
GAS LOGS
HOODS 1comm w1M
RANGES
GAS WATER HEATERS
WATER CLOSETS poueU _
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I certify under penalty of perjury that the irtformation 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 f_ DATE 2 �I (�,
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
ii NEW ❑ ADDITION
❑ ALTERATION
a REPAIR ❑ TENANT I WROVEMENT
BUILDING SHELL ONLY?
❑ YES ❑ NO
BASIC PLAN? ii 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 #IW - January 7, 2005
Page 2 of 4
k\Handouts\Permit Application