07-103518Y OFg. RECEI\&
Federal way PERMIT �5 L a -
COMMUNITY DEVELOPMENT SERVICA UN 2 8 ZOO % SF MF CO ME EL PL DE EN
33325 8"' AVENUE SOUTH • BOX 9718 PLIC ATI O N
FEDERAL WAY, WA 9806363 -9718
253-8352607•FAX 253-839'AC�Y OF FEDER
Letigo_caUr,;:edrr.:itl�ny_tt�rn BUILDING DEPT,
The following is required ir{formation - an incomplete application will not be accepted. Please print legibly (in ink) or type.
�0> 00wa J itlAi r^M-"riL It % --„J — !_ " „Z _} I_ t—L <-\ SIZE (sj)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) 2UItC \ o �( �'1 acya V"�j \ 1 L ``/es
(Attach separate page) lengthy legal descrlptlory
M PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
ElDEMOLITION ❑ ELECTRICAL ElENGINEERING VIRE PREVENTION SYSTEM
DESCRIPTION (Provide detailed deccrintinn of imrk rnchtrloA — this /"
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE• •
PROPERTY
OWNER
CONTRACTOR
CO{'Y o[ earl tegai[ed ��
APPPbCANT "
PROJECT
CONTACT
LENDER
NAME
Per RCW 19.27.095:
Lender information is required (f project value exceeds $5,000
MAILING ADDRESS
PRIMARY PHONE
PHONE
MAILING ADDRESS
CITY, STATE, ZIP
E-MAIL ADDRESS
COMPANY NAME _
APPLICANT NAME
OFFICE PH
�
Q
(X )M
MAILING ADDRESS
►- tV)
�' E E
CITY, STATE,Z
—CICO 1k
' �' Z
CELL PHONE
( ) -
CITY F FEDERAL WAY BUSINESS LICENSE NUMBER
i C1 -� - QW0 s -CCS-
EXPIRATION DATE
L k2 3 0 -7
FAX NUMBER
(�3) a'2� - 2 -?>C3'
CONTRACTOR'S REGISTRATION NUMBER
/
EXPIRATION DA
E-MAIL ADDRESS
O
COMPANY NAMELICANT
NAME
OFFICE PHONE
(
LI,G ADDRESS n _
S 'i_II
CITY, STATE, ZIP
_--
O p i
CELL PHONE
( ) -
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant
❑ Agent 50,Other Mol[53
)
NAME PRIMARY P NE E-MAIL ADD
NAME
Per RCW 19.27.095:
Lender information is required (f project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING USE �e S La r Cl n� _ PROPOSED USE �)-e s 1 Q u rant
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 2O �1J
SPRINKLERED BUILDING? YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED?(v ES ❑ NO
WATER SERVICE PROVIDER HAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER k', HAVEN 0 HIGHLINE ❑ PRIVATE (SEPTIC)
PROJECT ••
AREA DESCRIPTION EXISTING
SQ. FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
FIRST
HOODS (comm -14
COMPRESSORS
FURNACES
SECOND
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
THIRD
o YES
c NO
NEW ADDRESS REQUIRED? ❑
ADDITIONAL FLOORS (DESCRIBE)
UP/SEPA/SU?
c YES
c NO
DECK (❑ COVERED OR ❑ UNCOVERED?)
DEMO PERMIT REQUIRED?
❑ YES
c NO
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
F�verlvG
PROPOS®
TOTAL
TOTAL EXISTING SF
TOTAL PROPOSED SF
TOTALSF
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
N FIXTURES
Indicate number of each type of fi ture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work
(ACOP OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS PIPE OUTLETS WOODSTOVES
BBgS
FANS
GAS WATER HEATERS MISC (Describe)
BOILERS
FIREPLACE INSERTS
HOODS (comm -14
COMPRESSORS
FURNACES
RANGES
DUCTS
GAS LOG SETS
REFRIG. SYSTEMS
PLUMBING
BATHTUBS (or Tub/Sb,werCombo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
LAVS (Bathroom Sinks)
RAINWATER SYST
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
WATER CLOSETS rroueu
WASHING MACHINES
MISC (Describe)
I certify under penalty of perjury that the irlformation 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, andfiled 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 l un
(Signature)
RELATIONSHIP TO PROJECT ❑ Ler ❑ Agent
Mtle)
❑ Architect
FOR OFFICE USE ONLY
c NEW ❑ ADDITION
❑ ALTERATION
❑ REPAIR c TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑ YES ❑ NO
BASIC PLAN?
❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE?
o YES
c NO
NEW ADDRESS REQUIRED? ❑
YES c NO
UP/SEPA/SU?
c YES
c NO
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED?
❑ YES
c NO
Bulletin #100 — January 1, 2007
Page 2 of 4
k\Handouts\Permit Application