07-101755CITY OF-.� � � � � � •�
Federal Way -(FIVES PERMIT - - 1
COMMUNITY DEVELOPMENT SERVICES SF MF CO ME EL PL DE ENFP
33325 8TH AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, FAX
98063 O 22001 APPLICATION T° -
253-835-2607• FAX 253-835-260-260 9
unuue rilr n(er#�raluaur.rnm / /-` The following is r ;�ERA�
f g required {3 il! - an incomplete application will not be accepted. Please print legibly (in ink) or type.
SITE ADDRESS
ASSESSOR'S TAX/PARCEL #
M
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
LOT SIZE (sj)
(Attach separate page for lengthy legal description)
PROJECT• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DES�CyRIPTION (Provide detailed description of work included on this permit only)
PROJECT NAME (Name of Business or Owner Last Name) �b R r 4-0 1.11, N Cl.- ' —Cfl
PEOPLE•- •
PROPERTY
OWNER
CONTRACTOR
COPY of card requlred
with each rpplicatlon
PROJECT
CONTACT
LENDER
EXISTING USE
NAM(/E�/J��/`ti�,�" 17,'r -
/(PRIMARY
OWNER (�-
PHONE
I AD S
Yg�'pT 1�. l �/
L
E-MAIL ADDRESS
C MPAN�'_NAM / APPLICANT NA ,
FFICE PHONE
�I �DD CITY,$7' TE, ZIP
C P �.
CI OF FEDERAL WAY BUSINESS LICENSE NUMBER EX I ION DATE
FAX NUM ,
CO/N/T'JRACTOR'S REGISTRATION NUMBER
7 - EXPIRATION DATE
E-MAIL ADDRESS
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILINGADDRESS
CITY, STATE, ZIP -
(CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other
_
NAME
PRIMARY PHONE
E-MAIL ADDRESS
NAME
Per RCW 19,27.095:
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ V1i�UE OF PROPOSED WORK $
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)
15 3D
AREA DESCRIPTI
EXISTING
SQ. FT.
PROPOSED
SQ. FT.
TO1:
S . r T.
BASEMENT
❑ YES o NO
BASIC PLAN?
❑ YES
FIRST
ZONING DESIGNATION
C
CHANGE OF USE?
SECOND
o NO
NEW ADDRESS REQUIRED?
❑ YES ❑ NO
THIRD
D YES
a NO
PLATTED LOT?
ADDITIONAL FLOORS (DESCRIBE)
DEMO PERMIT REQUIRED?
a YES
o NO
DECK (❑ COVERED OR D UNCOVERED?)
GARAGE Cl CARPORT Q
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL EXISTING SF
TOTAL PROPOSED Sr
TOTAL Sr
"'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.
MECHANICAL
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS:_
PLUMBING
BATHTUBS (or Tub/Shower Combo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
(A COPOF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
EVAPORATI COOLERS GAS PWE OUTLETS WOODSTOVES
FANS GAS WATER HEATERS MISC (Describe)
FIREPLACE INSER'T'S HOODS (commercial)
FURNACES RANGES
GAS LOG SETS REFRIG. SYSTEMS
LAVS (Bathroom Sink:) URINALS MISC (Describe)
RAINWATER SYST VACUUM BREAKERS
SHOWERS WATER CLOSETS rroueq
SINKS WASHING MACHINES
SUMPS _
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 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 includi. g its officers and employees, upon the accurac of the information supplied to the city as a part of
this application.
DATE
NAME/TITLE
Signature) (Title)
RELATIONS P TO PROJECT o Agent ��ontractor ❑ Architect ❑ Other
F` L F ..
o NEW ❑ ADDITION
❑ ALTERATION
o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY?
❑ YES o NO
BASIC PLAN?
❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
o NO
NEW ADDRESS REQUIRED?
❑ YES ❑ NO
UP/SEPA/SU?
D YES
a NO
PLATTED LOT?
o YES o NO
DEMO PERMIT REQUIRED?
a YES
o NO
Bulletin #100 —January], 2007 Page 2 of 4 k\Handouts\Permit Application