04-102063crry of ti
Federal Way
COMMUNITY DEVELOPMENT SERVICES
33530 FIRST WAY SOUTH • PO BOX 9718
FEDERAL WAY, WA 98063-9718
253-6614115• FAX 253-6614129
www. dh/o(Tede rdwa n. mm
The follourinq is require
PER RCP. i_.
MF O E EL PL DE EN FP
APPLICATIOJJY 2g' -4-
NJ�40
- an incomplete
YPlease
SITE ADDRESS 3K, 2-0Oj/r✓�f)��% SUITE/UNIT #
ASSESSOR'S TAX/PARCEL # _ - LOT SIZE (s�
LEGAL DESCRIPTION (e.g, Acme Estates, Lot 1)
(Attach sepamfepage jor Ie glhy legal d—ipt—)
or
TYPE OF PERMIT DING PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DDESCRIPTION (Provide detailed description of work included on this permit onlu)
PROJECT NAME (Name of Business or Owner Last Name) C /L13Z,.12y � 114Qz2
PEOPLEINFORMATION
PROPERTY
NAME PHONE
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
MAILING ADDRESS CITY, STATE, ZIP
COMPANY NA E
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION
DATE
FAX NUMBER
— — — — — — — — — --B L
CONTRACTORS REGISTRATION NUMBER (copy o[ card r"ui—d with each application(
EXPIRATION DATE
COMPANY NAME
C -
APPLICANT NAME
/ A,
OFFICE PHONE
(I'll S-3 )
MAILING ADDRESS CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
(4kv- U)' S - 23Z
FAX NUMBER
V5-3 ) k ` v
NAM
PRIMARY PHONE
E-MAIL ADDRESS
Per RCW 19.27.095: Lender information is
NAME
required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
EXISTING ASSESSED/APPRAISED VALUE $
SPRINKLERED BUILDING? ❑ YES l' NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVEN
PROPOSED USE 6A/Mg
VALUE OF PROPOSED WORK $
FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED? ❑ YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING S . FT.
PROPOSED SQ. FT.
TOTAL
BASEMENT,, «
FANS
HOODS (Commercial)
WOODSTOVES
� � 1
Raw WT%
's
FIREPLACE INSERTS
RANGES
MISC (Describe)
SECOND
FURNACES
GAS WATER HEATERS
NEW ADDRESS REQUIRED? ❑ YES 'WNO
THIRD
GAS PIPE OUTLETS
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
SHOWERS
WATER CLOSETS goikt)
MISC (Describe)
DECK(COVERED?)
SINKS
DRINKING FOUNTAINS
GARAGE/CARPORT
SUMPS
RAINWATER SYST p
HOW MANY FLOORS?
TOTAL. FXISTLFG
TOTAPROPOSED
L.
TOTAL. rMS MG MD PROPOSED
"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 $
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
BBQS
FANS
HOODS (Commercial)
WOODSTOVES
BOILERS
FIREPLACE INSERTS
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
GAS WATER HEATERS
NEW ADDRESS REQUIRED? ❑ YES 'WNO
DUCTS
GAS PIPE OUTLETS
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
PLUMBING
BATHTUBS (or Tub/Sho Combo)
SHOWERS
WATER CLOSETS goikt)
MISC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPE OUTLETS
SUMPS
RAINWATER SYST p
WASHING MACHINES
URINALS
Z HOSE BIBBS I R / ®G
LAVS (Bau,omSi ks)
VACUUM BREAKERS
ELECTRIC WATER HEATERS
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 o cers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE
--(SIgRaTu rel
(l
rtLe�
RELATIONSHIP TO PROJECT ❑ Owner X Agent Contractor ❑ Architect ❑
DATE S L O T
FOR OFFICE USE ONLY
❑ NEW X -ADDITION
❑ ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES O
BASIC PLAN? o YES
"IAO
ZONING DESIGNATION
CHANGE OF USE? ❑ YES
�Rr-N0
NEW ADDRESS REQUIRED? ❑ YES 'WNO
U SEPA/SU? ,ofES
❑ NO
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
;AO
Bulletin #100 — March 30, 2004
Page 2 of 4
k\Handouts — Revised\Permit Application