04-103975 1/4- •
Federal
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Feeral WayECEIVEA
PERMIT 4)ECOMMUNITY DEVELOPMENT SERVICEAVENUE SOU77I•PO BOX QS SF MF O E E EN FP
3332 FEDERAL WAY,WA98 260'JILL 2 9 20APPLICATIO ID
253-835-2607•FAX 253-83535-2609 / /
u'wutatuo/l'ederdwa i. r1-
Y pF FEDER,
The following is re4Wri ai iily.t ;roan in •mplete ap.lication will not be accepted. Please print legibly(in ink)or type.
--• ( -/• .../ , :_:, '�J. 1I PROPERTY INFORMATION
SITE ADDRESS / / SO -L? ef/-1/7- , o \ SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# _ - ) LOT SIZE(sj)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
Attach separate page for lengthy I-.. .escnption)
/a! PROJECT INFORMATION
TYPE OF PERM / L)K Prl<�/J'' )y BUILDING ❑ PLUMBING ■ ' HANICAL
❑ DEMOLITION 0 ELECTRICAL ❑ ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJ cT ,' CRIPTION(Provide detailed description of work included on th'-permit only)
// / ip, !s/ 2✓ ' ' Ar c?_ -d 1-Gl i -/►......- a%/'n -l'
i
PROJECT NAME(Name of Business or Owner Last Name) /5_I ( G 7,7
'' -, II PEOPLE INFORMATION
PROPERTYN �� PRIMARY PHONE
OWNER � /7/�%.57 (/ `I1)C-7-/ 6'3) 97/ Z7//
MAILING ADS�S(j� ,// CITY, ,,/p,ZIP
,/_,/-L.:27. ,),,,,.. , --cr.,e,5-
CONTRACTOR COMPA ''GAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE '/ 9'
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
- -B L / / ( ) -
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
I APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
( )
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT - FAX NUMBER
❑ Architect ❑ Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
( )
LENDER Per RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP
/.i DETAILED BUILDING INFORMATION -
EXISTING USE �/- ifiC el./7/ PROPOSED USE /917 S 7/\- / (;//..oi✓G'-�—
,� �pp.�'/-S
EXISTING ASSESSED/APPRAISED VALUE $-�, '75�O OQ . VALUE OF PROPOSED WORK $ ^G'r'O,
SPRINKLERED BUILDING? %YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
' WATER SERVICE PROVIDER ,le LAKEHAVEN 0 HIGHLINE a TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER )(LAKEHAVEN a I IGHLINE ❑ PRIVATE(SEPTIC)
I
530':z IVO
PROJECT FLOORAREAS
AREA DESCRIPTION EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST —
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE) \
DECK(COVERED?
GARAGE/CARPORT
HOW MANY FLOORS? TOTAL[JOSTLED TOTAL.PROPOSED TOTAL EXISTING AED PM POSED
"NEW HOMES ONLY"' NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $__
Indicate number of each type of fixture to be installed or relccated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS icomm.row) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING ^-
BATHTUBS or Tub/Shower Combo( V SHOWERS WATER CLOSETS troaoq MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sinks) VACUUM BREAKERS ELECTRIC WATER HEATERS I
An$OyAINER/$IGNATQREBLOCR
I certify under penalty of perjury that the in ormation 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 per •t. including the undersigned, and filed against the City of Federal Way,but only where such claim
arises out of the relian of the city, including s officers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME TITLE 4"1".°: . .7"41-7,7 DATE a � ofri
/ (Signature) (Title) P
( RELATIONSHIP TO PROJECT 0 Owner 0 Agent o Contractor 0 Architect 0 Othe
FOR OFFICE USE ONLY
o NEW o ADDITION a ALTERATION o REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES o NO BASIC PLAN? a YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑YES a NO
NEW ADDRESS REQUIRED? o YES a NO UP/SEPA/SU? o YES a NO
PLATTED LOT? ❑YES ❑NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#100 March 30,2004
Page 2 of 4 k\Handouts—Rcvised\Pcrmit Application