07-100679CITY OF .Supine - d
Federal way $ERMIT-
COMMUMTYDEVELOPMENrSERVICES FEB 0 7 2007 SF MF CO ME EL PL DE EN JFP
33325 AVENUE. WA 9• PO BOX 9718 P T I CATI O N
FEDERAL WAY. WA 98063-9718
253-835-2607• FAX 253-835-20TY OF FEU l
au+tc.cfrtiQf ederrducur.tvrr` BUILDING DEPT -
The following is required information - an incomplete application will not be accepted. Please print legibly (in ink) or type.
PROPERTY INFORMATION
�,Q
SITE ADDRESS 1 � ( V c- S SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # _ 2/- 6 s /'c' LOT SIZE (s))
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate pagejor lengthy legal descriptiory
PROJECT• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL El/ ENGINEERING ® FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
Ins4wil Fisc. Svcru.\er Soss em %,\ Shell Q.t�tc1:Na
PROJECT NAME (Name of Business or Owner Last Nam e1 1"�-oa
PROPERTY
OWNER
CONTRACTOR
COPY of card required
with each application
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME r - 1
I e
MAILING ADDRESS CITY, TATE, ZIP
3'700
PRIMARY PHONE
E-MAIL ADDRESS
��.�c �o�- � ►rc �co'tcc.�-ion
PLICANT NAME
gtb f csb
FFICE NE
cL53P) G23`) -3Ho5
MAILINGINAME
2-10-1 D1 D�Ave- G
�aLL.0ATE, ZIP 1 .t \ k -Rl X0-4
CELL PHONE -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
1 `)- q 1_1014 (7le63- op -BL
EXPIRATION DATE
Q.1
FAX NUMBER
(ts3 ) t,3,61 -3406
CONTRACTORS REGISTRATION NUMBER
PAT R1 Ft 0ORF-
EXPIRATION DATE
ID/051 63Oa
E-MAIL ADDRESS
1.6E6
GG Ac-F:ce?cd"60
b NAME
a3L$H -31-103
(ZP)��b}
MAILING ADDRESS
21.0-1 tor' AveNie- S
CITY, STATE, ZIP -
T^4z['%.. wry 3141 i
CELL PHONE
( ) -
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent it Other
FAX NUMBER
(2,53) 7.3,1 -3406
NAME Fd cs 6ec PRIMARY PE E -MA ADDRESS
(l53)HON84-.1,io5 bab Ca?c��r:o�F;ce.c�N.
NAME
Per RCW 19.27.095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE ZP-%A,4 ,/f4 -i / nC.i ca I
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? IYES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER IV/LAKEHAVEN ❑ HIGHLINE ❑ TACOMA n PRIVATE (WELL)
SEWER SERVICE PROVIDER Cil LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
PROJECT •••
AREA D ION
AREAS
GAS PIPE OUTLETS WOODSTOVES
BBQS
EIIISPROPOSED
5g. FT.
5Q. FT.
TOTAL
S . FT.
BASEMENT
HOODS (commemu)
COMPRESSORS
FURNACES
FIRST
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
SECOND
u YES
❑ NO
NEW ADDRESS REQUIRED? ❑
THIRD
UP/SEPA/SU?
u YES
a NO
ADDITIONAL FLOORS (DESCRIBE)
DEMO PERMIT REQUIRED?
❑ YES
u NO
DECK (❑ COVERED OR ❑ UNCOVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL EXISTING SF
TOTAL PROPOSED SF
TOTAL SF
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work $
(A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
BBQS
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
FIREPLACE INSERTS
HOODS (commemu)
COMPRESSORS
FURNACES
RANGES
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
PLUMBING
BATHTUBS (or Tub/Sho—r Combo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
LAVS (Bathroom Sinks)
URINALS MISC (Describe)
RAINWATER SYST
VACUUM BREAKERS
SHOWERS
WATER CLOSETS rroitet)
SINKS
WASHING MACHINES
SUMPS
BUILDING SHELL ONLY? ❑ YES ❑ NO
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 1
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 p �c�� Cs�� I ip • eA DATE
(Signature) / (Title)
RELATIONSHIP TO PROJECT ❑ Owner Ll Agent Of Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
❑ NEW u ADDITION
❑ ALTERATION
❑ REPAIR ; i TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑ YES ❑ NO
BAS1,C PLAN?
❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE?
u YES
❑ NO
NEW ADDRESS REQUIRED? ❑
YES ❑ NO
UP/SEPA/SU?
u YES
a NO
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED?
❑ YES
u NO
Bulletin #100— January 1, 2007 Paee 2 of 4 k\Handouts\Permit Application