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ACONSTRUCTION PERMIT APPLICATION
CITY OF 9/, S o 3 APPLICATION NUMBER: 03- 1 Q IH' 2.I1 - Z)
Federal Way APPLICATION NUMBER: -
APPLICATION NUMBER: - -
**The following is required information—Please print(in ink)or type**
Please note: Electrical,Fire Prevention Systems and Engineering permits may require a separate application.
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• PROPERTY INFORMATION
SITE ADDRESS: I�SSS `s PO( r IL R lAiy ASSESSOR'S TAX/PARCEL#:0 CI 2 i O_Lt - S 2 O L
LEGZDESCR,IPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
alt
• PROJECT INFORMATION
TYPE OF PROJECT(This application): ❑ BUILDING o PWMBING ❑MECHANICAL o DEMOLITION
0 ELECTRICAL o ENGINEERING IRErIPPREVENTI jON SYSTEM
PROJECT DESCRIPTION(Provide detailed description): l P -PvI{ r VIn n...... 91-6-e-\
PROJECT NAME: -if n K C Ifi-H(11 V 01
• PROJECT INFORMATION
PROPERTY OWNER: NAME: DAYTIME PHONE:
C U3 C 6.(Th U C-H10)1 (ZC(2 )6721 -9111
MAILING (STREET AD ;CITY,STATE,ZIP):
-7 n l D ex-Fe,X'' 4ve- -?.0 eG ,u )rt
CONTRACTOR: NAME: DAYTIME PHONE:
t Lt(- -r iCcc 1cf rinolo(37 (42S ) L(O7 - .s ci
M0411NG ADDRESS(STREET i i'i.;CITY,STATE,ZIP): / EVENING PHONE:
1 (> erx 12iL2 ) ifi i l( Cyr( r, wif arc g ( ) 6,01,,70
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: - - (/1�j MB)k -(5, -/-)
CONTRACTORS REGISTRATION NUMBER: /� EXPIRATION DATE:
(c py or card ) tit / T t O 1 g m A / l
APPLICANT: NAME: DAYTIME PHONE:
mob--ed-y- c cd. �C r-,,n'bA.o`-�J 9,V (q )u oz - r‘&1 3
MAILING ADDig(STREET Z (�A ��1\ C.i l.-L I C�J A EVENING PHONE:
b\t. -
TIONSHIPTOPROJECT: � FAX NUMBER:
❑ARCHITECT 0 TENANT IXOTHER(DESCRIBE): l/1 aftl{�`y U1 (2gy(p() ) 5G-7 - (I)
E-MAIL ADDRESS: f"
CONTACT PERSON FOR THIS PROJECT: ❑PROPERTY OWNER ❑APPLICANT ❑CONTRACTOR (I,[C'fYICC k(,vIaq./6 VtriZ0,11 (76
• PROJECT INFORMATION
EXISTING USE: I EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
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PROPOSED USE: (*V1 (\Cl Sk re _ PROPOSED VALUATION FOR IMPROVEMENTS: V I C)C )
SPRINKLERED BUILDING? )(YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED:AYES ❑NO
WATER SERVICE PROVIDER: 0 LAKEHAVEN ❑ HIGHLINE ❑TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE o PRIVATE(SEPTIC)
•
•
**NEW RESIDENTIAL CONSTRUCTION ONLY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
• PROJECT FLOOR AREAS
FLOOR EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND l N�
THIRD
FOURTH
OTHER FLOORS(DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS? i
TOTAL: ` t , c- c
• FIXTURES
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS LOG(S) REFRIG.SYSTEM(S)
BBQ(S) FAN(S) HOOD(S) WOODSTOVE(S)
BOILER(S) FIREPLACE INSERT(S) RANGE(S) MISC.( )
COMPRESSOR(S) 3 FURNACE(S)
DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: o ELECTRIC o GAS
PLUMBING
BATHTUB(S) LAVATORY(S) a URINAL(S) WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKERS) ELECTRIC o GAS
DRINKING FOUNTAIN(S) ' SHOWER(S) WASH MACHINE OUTLET ,- ��•II C
GAS PIPE OUTLET(S) 1 SINK(S) WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
■ 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 daim(induding costs,expenses,and attorneys'fees Incurred in the
investigation and defense of such daim),which may be made by any person,induding the undersigned,and filed against the City of
Federal Way,but only claim arises out of the reliance of the city,including its officers and employees,upon the accuracy
of the Information s ••
• as a part of this application.
N AME/TITLE: 0tson-e-C� DATE:
or)
o PROPERTY OWNER o APPLICANT o CONTRACTOR
FOR OFFICE USE ONLY:
o NEW o ADDITION o ALTERATION o REPAIR o TENANT IMPROVEMENT
CENSUS CODE: LOT SIZE:
ZONING DESIGNATION: BUILDING SHELL ONLY? o YES o NO
COMP PLAN DESIGNATION BASIC PLAN? o YES o NO
SECTION TOWNSHIP RANGE NEW ADDRESS REQUIRED? o YES o NO
PLATTED LOT? o YES o NO CHANGE OF USE? o YES o NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH•PO BOX 9718•FEDERAL WAY,WA 98063-9718•253-661-4000•FAX:253-6614129
www.cityoffederalway.com