07-101724RECEIAD 4
CITYOF 4k L- a -
Federal way APR o 2 2007 PERMIT �L (��`^��]
COMMUNITY DEVELOPMENT SERVICES SF MF CO ME EL PL DE EN ``/
33325 I AVENUE SOUTH . PO BOX 9718
FEDERAL,WAY, WA OF FEDE IRfI L I C ATI O N
2532607,X213-.1-291TY
wiviv. cituo aluny canDUILDING
The following is required information - an incomplete application will not be accepted. Please print legibly (in ink) or type.
PROPERTYI • •
SITE ADDRESS I6oa C'0 - Dr) Ve 6ck-) SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # A --3 2 1 O -I, - ` (' -!2- &- LOT SIZE (sfl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot]) SLX t' V a
(Attach separate pogef lengthy Ngal d-77;tinn)
PROJECT• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING [FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Prouide detailed description of work included on this permit onlu)
n sin
o
v l
PROJECT NAME (Name of Business or Owner Last Namel T�I�RX TCS V Q),AC,-.li'tz.
PEOPLE•• •
PROPERTY NAME PRIMARY PHONE
OWNER ( ) -
MAILING ADDRESS CITY, STATE, ZIP E-MAIL ADDRESS
CONTRACTOR
COPY of card required
with euch applic,ti—
APPLICANT
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
e -T
( ) -+a U- G
MAILING ADDRESS
CITY. STATE, ZIP
CELL PHONE
(P166 I a
5.
( ) -
RELATIONSHIP TO PROJECT
i
FAX NUMBER
❑ Architect ❑ Tenant
❑ Agent A Other
('11 ntr a.c ro ►K
( ) -
PROJECT NAME_ PRIMARY PHONE E-MAIL ADDRESS
CONTACT 1 ( ) �-
LENDER NAME Per RCW 19.27.095:
Lender information is required ifproject value exceeds $5,000
MAILING ADDRESS CITY, STATE, ZIP PHONE
EXISTING USE
EXISTING ASSESSED/APPRAISED VALUE $
PROPOSED USE
VALUE OF PROPOSED WORK $ 2 ,e� 0
SPRINKLERED BUILDING? ❑ YES C NO FIRE SUPPRESSION SYSTEM PROPOSED/REgUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
a
PROJECT••• AREAS
AREA DESCRIPTION EXISTING PROPOSED
S . FT. S . FT.
TOTAL
SQ. FT.
BASEMENT
n NEW ADDITION
FIRST
c REPAIR ❑ TENANT IMPROVEMENT
SECOND
YES , NO
BASIC PLAN?
THIRD
❑ NO
ZONING DESIGNATION
ADDITIONAL FLOORS (DESCRIBE)
CHANGE OF USE?
❑ YES
DECK (❑ COVERED OR ❑ UNCOVERED?)
NEW ADDRESS REQUIRED? EYES
--NO
GARAGE ❑ CARPORT ❑
❑ YES
❑ NO
NUMBER OF FLOORS
� '
°Koro
corer
ToreLF-133MGSF rone ,moms®sr
TOTAL SP
"NEW HOMES ONLY" NUMBER OF ROOMS ESTIMATED SELLING PRICE $\
Indicate number of each type offixture to be instilled or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL ,
of Mechanical Work $—a7 -!s `lC7 , Or -
Value (A COPY OF BID OR ESTIMATE MUST BE IN5=Li WITH APPLICATION)
AIR HANDLING UNITS
BBgS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS (or Tub/Shower Combo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
EVAPORATIVE COOLERS -,,__GAS PIPE OUTLETS
FANS GAS WATER HEATERS
FIREPLACE INSERTS
FURNACES /
GAS LOG SETS
FT
--m Slnks)
ER SYST
RS
SINKS
SUMPS
_ HOODS (Con—miall
RANGES
REFRIG. SYSTEMS
URINAL
VACUUM BREAKERS
WATER CLOSETS rrotlet)
WASHING MACHINES
WOODSTOVES
MISC (Describe)
Flre S�t"�SS�cr1
s�s-rexY,
C, utr3ao�
MISC (Describe)
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 city, including its officers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE DATE
(Signature- (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other__
3/02
FOR OFFICE USE ONLY
n NEW ADDITION
n ALTERATION
c REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY?
YES , NO
BASIC PLAN?
❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
❑ NO
NEW ADDRESS REQUIRED? EYES
--NO
UP/SEPA/SU?
❑ YES
❑ NO
PLATTED LOT? -YES .,NO
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
Bulletin #100 - January I, 2007 Page 2 of 4 k\Handouts\Permit Application