05-100275 4 7,1L
• CITY OF as__
- I V (2_ Y • -7 S
Federal Way
COMMUN�I'S•DEVELOPMENT SERVICES PERMIT SF MF �� �E �' DE EN FP
33325 8n'AVENUE SOUTH•PO BOR 9718 APPLICATION
FEDERAL WAY,WA 98063-9718 TD 1
253-835-2607•FAX 253-835-2609 h �
�
n ,
www.cituoffederaiwau.00m
The ollowin• is re•aired in ormation-an incom•lete • ••lication will not be acce•ted. Please •rent le• •I n i or t. • .
• PROPERTY INFORMATION
SITE ADDRESS SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# _ _ __ _ LOT SIZE N)
LEGAL DESCRIPTION(e.g.Acme Estates, Lot 1)
(Attach separate page for lengthy legal desenpnon)
• PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING ❑ PLUMBING 0 MECHANICAL
0 DEMOLITION ELECTRICAL 0 ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
PROJECT NAME(Name of Business or Owner Last Name)
PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER (. ) -
MAILING ADDRESS CITY,STATE,ZIP
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
)
L P>� ESS CITY,STATE,ZIP CELL PHONE
lIV\ l )
`I OF FE RAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
- - BL ( )
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
�1 ) - ' -
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
)
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect 0 Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
LENDER Per RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 3G291.1 00 C)
SPRINKLERED BUILDING? YES - NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? KYES 0 NO
WATER SERVICE PROVIDER Li LAKEHAVEN i HIGHLINE TACOMA PRIVATE (WELL) Sv'uhi/ F t e
SEWER SERVICE PROVIDER -1,LAKEHAVEN ❑ HIGHLINE PRIVATE (SEPTIC) Q)S✓ r�Ql6G 18 O
5807.16.2 ��
i OP
• •
P { ,
PROJECT FLOOR AREAS
✓r AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ. FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT 0
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING SP TOTAL PROPOSED SP TOTAL SP
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. 1)o not include existing fixtures to remain.
MECHANICAL@,Value of Mechanical Work $ 1 p
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commercial) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES 9 GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING 1
BATHTUBS(or Tub/Shower combo) _ SHOWERS WATER CLOSETS(miles MISC(Describe)
DISHWASHERS / i SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAYS(Bathroom sink.) VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
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.
gyfty---------..„
NAME/TITLEDATE
(Signature) 1 Pitle)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor Architect Other
FOR OFFICE USE ONLY
LI NEW i i ADDITION ALTERATION u REPAIR TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES a NO BASIC PLAN? YES NO
ZONING DESIGNATION CHANGE OF USE? YES NO
NEW ADDRESS REQUIRED? ❑YES a NO UP/SEPA/SU? YES NO
PLATTED LOT? i I YES ❑NO DEMO PERMIT REQUIRED? LI YES ❑NO
LD
Bulletin#100 August 19,2004 Page 2 of 4 k\Handouts\Permit Application