01-103863 • RECE!VMIS I RU•ON PERMIT APPLICATION
VV F-�Y APPLICATION NUMBER: 01 - 10,3 r/l��-F?
OCT 03 2 M LICATION NUMBER: - _ _ _
CITY of DING DEPTFEDER P �FATION NUMBER: - - _
BUIL . — —
**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.
PROPERTY INFORMATION
3L.(A. .Jeysa.•14suss2 W•
s
SITE ADDRESS: ASSESSOR'S TAX/PARCEL #: -
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
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PROIECT_INFORMATION
TYPE OF PROJECT(This application): ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING% FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description): pon,“ r U L Sc c L. i p at 1-r) Ey l S r1•./C1
IZ%rL«l±".1 S re—MS . /2,4,1A-C-G- A.LA- 4.124.‘ C.I_��.., c�sL- 5 1 SrG--, S
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PROJECT NAME: hU ,4,!'
'PROPERTY OWNER: NAME: DAYTIME PHONE:
WE E-4,W4*uSE2 (Z5'3 )(ivy -`13S1(
MAILING-ADDRESS(STREET ADDRESS;CITY,STATE,ZIP):
33(4[..3 4-1E-‘1 ea-turc-usc-a- uJA s w Csoe-eA �,�1a..� , wa O7 )
CONTRACTOR: NAME' DAYTIME PHONE:
c12E Fito rL--c-no^J _ (t53 ) 731 - zLou
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
t L20 31" Sr 5u‘Te la Le 4..)13„2•J,WA 91001 (
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: FAX NUMBER:
ci L 8_ - c{4-0081. (253)'331 - 2366
CONTRACTOR'S REGISTRATION NUMBER: �• . EXPIRATION DATE:
(copy of card required) (� P _ 1) E ' LE I Z / �7 1 / Q 1
APPLICANT: N
DAYTIME PHONE:
tc -LA CtLEESL ( ) 3-4- =46M NG ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
12t oto k C( iOlo, A.13 L-/
RELATIONSHIP TO PROJECT- - FAX NUMBER:
❑ ARCHITECT ❑ TENANT OTHER(DESCRIBE):C o%N"7 eke— (253) 134-
I
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ►. • 'PLICANT ❑ CONTRACTOR
BUILDING
EXISTING USE: EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: $ 28O
SPRINKLERED BUILDING? YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: YES ❑ NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
• •
**NEW RESIDENTIAL CONSTRUCTION ONLY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
■ PRO]ECT FLOOR AREAS
FLOOR EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
OTHER FLOORS(DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
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 INSERTS) RANGE(S) MISC.(
COMPRESSOR(S) FURNACE(S)
DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: ❑ ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S) LAVATORY(S) URINAL(S) WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINKS) WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
-- . . = > ` _- ._ , a:•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 where such daim arises out of the reliance of the city,induding its officers and employees,upon the accuracy
of the information sup lied to the d as a part of this application. q
NAME/TITLE: _GI /A/ 9 cTt�L- DATE: ` 'Z5-0 J
❑ PROPERTY OWNER ❑ APPLICANT X CONTRACTOR
•
.FOROFFICE USE ONLY:
❑-NEW s �< ❑ADDITION 0 ALTERATION- - ''-:0,IiEkik • )l TENANT IMPROVEMENT
CENSUS CODE• = -LOTSIZE: 1 =
z•
iZONING D IGNATION:'- BUILDING`SHELL ONLY?-',❑ YES NO -
xCOMP:PLAN DESIGNATIONBASIC PLAN?-1 .YES" ❑ NO
;SECTION;',._ =_ ,TOWNSHIP RANGE NEW ADDRESS REQUIRED? ❑ YES 0N
PLATTED LOT? ❑ YES ❑ NO CHANGE OF USE? ❑YES ` ❑ NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH-PO BOX 9718•FEDERAL WAY,WA 98063-9718-253-661-4000•FAX:253-661-4129