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, Federa�way ��� � � 20��1ZMIT APPLICATiO 253�6»»5•FAX:253-6614729
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4 Fo�o�n��o�,Y �,�� DE A T _ 3 � —
� BUILDING DF�PT,
The ollowin is re uired in ormatiort-an incom lete a lication will not be acce ted. Please nnt ibl (irt inl�or e.
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� SITE ADDRESS: �ySZ� '�/ J`� � S : �� (/va.c, (.vt�, SUITE/APT# .
� ASSESSOR'S TAX/PARCEL#: 7 S D �f -S / - G' C� � 0 SQUARE FOOTAGE OF LOT:
LEGAL DESCRIPTION (e.g.:Acme Estates,Lof 1)
(Atfach separate page for lengthy legal descriptionJ
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TYPE OF PERMIT(This application): ❑ BUII,DING ❑ PLUIVI�ING ❑ MECHANICAL ❑ DEMOLITION
D ELECTRICAL ❑ ENGINEERING'�FIRE PREVENTION SYSTEM
PROJECT DESCFtIPTION(Provide detailed description of work included on this pe,�nut onluh.
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PROJECT NAME(Name of Business/Owner Lasf Nam�: �7-, �c.�'IC�S �Sr1,�� `�«�t3 �K l�tvtS�� ��� f'��
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PROPERTY NAME: PRIMARY PHONE:
OWNER 5 . I�✓ur�,u, .- e r l q e`: � � -
� MAfLING ADDRESS(STREET AD RESS;�: CITY,STATE,ZIP
CONTRACTOR ME COMPANY OFFICE PHONE:
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AILtNG ADD SS(STREET ADDRES ;�: CITY,STATE,ZIP CELL PHONE:
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� CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: EXPfRAT(ON DATE: . FAX NUMBER:
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CONTRAC'fOR5 REG[SfRATION NUMBER: EXPIRATION DATE:
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(copy of card reqn3red with each appllcation) � g / i� �-- r 7 � � � � � /� / S'_ /d
LENDER NAME: DAYTIME PHONE:
pr r,o�e v���>is,000� � � -
MAIL[NG ADDRESS�STREET ADDRESS;): CITY,STATE,ZIP
APPLICANT: NAME: COMPANY OFFICE PHONE:
�L. C `� � / L!+ o�ot C
AILING ADD ESS(STREET ADDRESS�. CITY,STATE,ZIP EVENING PHONE:
v, �7� Tz � � ��Yd �s3 � � G -aay�
RELATIONSHIP TO PROJECT: FAX NUMBER:
❑ Architect ❑ Tenant � Other(Describer J j � �o?o� (f,/��
CONTACT PERSON FOR THIS PROJECT: ❑ Property Owaer ❑ Contractor ❑ Applicaat E-MAIL ADD
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EXISTING USE: PROPOSED USE:
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK: $ _�s���vU
SPRINKLERED BUII.DING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED?: ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE o TACOMA O PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN o HIGHLINE O PRIVATE(SEPTIC)
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AFtEA DESCRIPTION EXISTING S .FT. PRO :D S . FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FIAORS? T�Tw�T�Nc' 707'AL PROPoSED TOTAL E7Q5IING AND PROPOSED
"NEW HOMES ONLY*• NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
Indicate number of each type of fixture that is to be installed or relocated as part of this project. Do not include existing fixtures to remain.
]KE(.HAI�IICAL
Value of Mechanical Work $
--AIR HANDLING UN[TS EVAPORATiVE COOLERS GAS LOGS REFRIG.SYSTEMS
ggQ$ FANS HOODS(comm�aq WOODSTOVES
BO[LERS FIREPLACE INSERTS RANGES MISC(Describe) �
__COMPRESSORS FURNACES G�S WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING �
BATHTUBS�arTun�sh�camca� SHOWERS WATER CIASEI'S Rou�q MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYS
WASHING MACHINES URINA►S HOSE BIBBS ,
LAVS�eau,�oom s;nlc VACUUM BREAKERS ELECTRIC WATER HEATERS i
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I cer�ify under penalty of perjury that the{nformation furnished by me is true acnd correct to the best of my ;
laeowiedge, and further, that I am authorized by the owner of tiee above premises to perform the work for which the permit i
appiication is made. I further agree to hoid harmTess the City of Federal.Way as to any cIaim(�ncTuding costs, expenses, and I
attorneys'fees incurred in the{nvestigation and defense of such ciaim), which rnay be made by any person, inciuding the
undersigned, and fiied against the City of Federal Way,but only where such cla�m arises out of the reiiance of the city, �
incIuding its officers and err:pioyees,upon the accuracy of the information suppiied to the c{ty as a part of this appii.cation.
NAME/TITLE: /�LSU�'�-- l��Ci'LC_� ���( /,C�1rCl�^'� DATE: �I�g/G' �/
F' / (Signature) (T�Ue)
RELATIONSAIP TO PROJECT: o Property Owner �Applicant o Contractor ❑ Architect ❑
FOR OFFICE,USE ONLY: •
❑NEW o ADDITION ❑AI.TERATION o REPAIR o TENANT IMPROVEMENT
BIIII.DING'SHELL ONLY?_ a YES ❑NO BASIC-PLAN? ❑YE.S a NO
,
ZONIIIG DESIGNATION: ` CHANGE OF USE? o YES ❑NO
NEW ADDRESS RF.QUIRED? ❑YES ❑NO UP/SEPAJSU? a YFS o NO
'Pl:ATTED LO'r? ❑YF.S ❑NO DEMO PERMIT EtEQUIRED? ❑YES ❑NO
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