07-106010RECEI E16
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Fo-daral Way V A 12007 PERMIT
COMMUP77Y DEVELOPMENT SERVICES SF MF CO ME EL PL DE EN P
33325AVENUE SOUTH • BOX 971) F
PLICATION
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FEDERAL WAY, WA 98063-9718 [=EpER o /
253-835-2607• FAX 253-835.2609° - --=,a
� omitno ederaiwng m7n �! Ill -.DING DE
The following is required information -an incomplete application will not be accepted. Please print legibly (in ink) or type.
d
% PROPERTY•. •
SITE ADDRESS _ e 5-X't/f/' Q� `: SUITE/UNIT #
0
ASSESSOR'S TAX/
LOT SIZE (sj)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate Page for 1e wfhy legal des ption)
PROJECT INFORMATION
TYPE OF PER41� 1 qo ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
XF
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERINGIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed glescription of work included on this permit onlu
PROJECT NAME (Name of Business or Owner
PROPERTY
OWNER
CONTRACTOR
APPLICANT
PROJECT
CONTACT
LENDER
EXISTING USE
NAME
(`PRIMARY PHONE
MAILING ADDRESS
CITY, STATE, ZIP
E-MAIL ADDRESS
COMPANY
NAME
OFFICE PHONE
APPLICANT NAME
OFFICE PHONE
MAILING ADDRE53 -
RELATIONSHIP TO PROJECT
CITY,
ATE, 1
�L o �
CELL P NE
)U -1 �-
CI OFFEDERALAY BUSINESS LICENSE
MBER E IRATION DAIE
FAX NUMBER
j , �,
CONTRACTOR'S REGISTRATION NUMB
EXPIRATION DATE
E-MAIL ADDRESS
lJ e�
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other
( _
NAME PRIMARY PHONE E-MAIL ADDRESS
1
NAME
Per RCW 19.27.095.
Lender information is required if project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED/APPRAISED VALUE $
PROPOSED USE
VALUE 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 0 LAKEHAVEN ❑ HIGHLINE 0 PRIVATE (SEPTIC)
PROJECT .••
AREA DESC N0�4.14&4911
AREAS
RAINWATER SYST
ING PROPOSED
6(2. FT. SQ. FT.
TOTAL
SQ. FT.
BASEMENT
SINKS
WASHING MACHINES
FIRST
BUILDING SHELL ONLY?
D YES D NO
SECOND
0 YES
ONO
THIRD
CHANGE OF USE?
ADDITIONAL FLOORS (DESCRIBE)
D NO
NEW ADDRESS REQUIRED?
DECK (❑ COVERED OR ❑ UNCOVERED?)
UP/SEPA/SU?
0 YES
GARAGE ❑ CARPORT ❑
PLATTED LOT?
0 YES 0 NO
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL
TOTAL Z=TM sr TOTAL PROPOSED sr
TOTAL er
""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
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or Tub/Shower Combo)
DISHWASHERS
DRINKING FOUNTAINS
ELECTRIC WATER HEATERS
HOSE BIBBS
(A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
FANS GAS WATER HEATERS MISC (Describe)
FIREPLACE INSERTS HOODS (Commercia4
FURNACES RANGES
GAS LOG SETS REFRIG. SYSTEMS
LAVS (Bathroom Sink.)
URINALS MISC (Describe)
RAINWATER SYST
VACUUM BREAKERS
SHOWERS
WATER CLOSETS iroike
SINKS
WASHING MACHINES
SUMPS
BUILDING SHELL ONLY?
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best of my
knowledge, the information submitted in support of this permit application is true and correct. I cert(fy that I will comply with all applicable
City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the issuance of this permit
does not remove the owner's responsibility for compliance with local, state, or federal laws regulating construction or environmental laws.
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, 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 apart of thq application n
TE
Bulletin # 100 - August 16, 2007 Page 2 of 4 k\Handouts\Permit Application
o NEW 0 ADDITION
D ALTERATION
0 REPAIR D TENANT IMPROVEMENT
BUILDING SHELL ONLY?
D YES D NO
BASIC PLAN?
0 YES
ONO
ZONING DESIGNATION
CHANGE OF USE?
D YES
D NO
NEW ADDRESS REQUIRED?
D YES ONO
UP/SEPA/SU?
0 YES
0 NO
PLATTED LOT?
0 YES 0 NO
DEMO PERMIT REQUIRED?
0 YES
D NO
Bulletin # 100 - August 16, 2007 Page 2 of 4 k\Handouts\Permit Application