04-1040371�
33325 8`h Avenue South
PO Box 9718 PERM,M- -�vED
Federal Way WA 98063-9718
253-835-2607, Fax 253.835.2609 A P P L I C A 1 `�i fl�
www.trit offederalwa .cam
inc rotiowina Is required information - an
SITE ADDRESS
ASSESSOR'S TAX/PARCEL #
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
� L1 .] V I [c
��- LP �( -�
„r' MF CO ME EL PL DE EN FP
[D (O 2S h)e(
ited. Please print lepiblu Fin inkl or Woe.
SUITE/UNIT #
LOT SIZE (sj)
(Attach separate pagefor lengthy legal desoiption)
TYPE OF PERMIT ❑ BUILDING - 1!I PLUMBING > MrCHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlul
/V lam% (IP
PROJECT NAME (Name of Business or Owner Last Name) & Vt-1 C r_& J
PEOPLE 1
PROPERTY
OWNER
CONTRACTOR
Fkj)-d pok
All
APPLICANT
�7
CONTACT
LENDER
EXISTING USE
NAME �^ PRIMARY PHONE
�Sc�utECl&S -L (as3) 9� y - ®/v
MAI G ADDRESS CITY, STATE, ZIP `
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
(
—CITYFEDERAL WAY 13USINESS UCE E NUMULR EXPMT1011 DATE
62(2 - 1 z
FAX NUMBER
-
S I3 I.
CONTRACTOWS REGISTRATION NUMBER (copy or card required with each application) EXPIRATION DATE
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
(
RELATIONSHIP TO PROJECT
1AX NUMDER
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
I ( ) -
NAME PRIMARY PHONE E-MAIL ADDRESS
Per RCW 19.27.095: Lender information is NAME
required if project value exceeds $5,000 K) //�
MAILING ADDRESS CITY, STATE, ZIP
EXISTING ASSESSED/APPRAISED VALUE $
nETAMED svrLDING MFORMATmN
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 ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
AREA DESCRIPTION
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS?
HOMES ONLY*" NUMBER OF BEDROOMS
EXISTING S . FT. PROPOSED S . FT. TOTAL
TOTAL EXISTING TOTAL PROPOSED TOTAL rJOSTDiG AND PROPOSED
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
BBQS
FANS
BOILERS
FIREPLACE INSERTS
COMPRESSORS
FURNACES
DUCTS
GAS PIPE OUTLETS
PLUMBING
BATHTUBS (or Tub/Sh-w rComb,)
SHOWERS
DISHWASHERS
SINKS
GAS PIPE OUTLETS
SUMPS
WASHING MACHINES
URINALS
LAYS Mathes wSink�VACUUM
BREAKERS BREAKERS
GAS LOGS
HOODS (com -ir d)
RANGES
GAS WATER HEATERS
WATER CLOSETS (Toney
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I_cerHfy under penal o perfury that the information furnished by me is true and correct to the best of my knowledge, and further, that I
am authorized bK.a9be7IZ*--
hwncr the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the Citday as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation and defense of
such claim) whie by any person, including the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the,relfance� the city, including its officers an ployees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE / DATE �_� �(.yl
[Sighwurel (Title( F — -I
RELATIONS IP PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
❑ NEW ❑ ADDITION
BUILDING SHELL ONLY?
ZONING DESIGNATION
NEW ADDRESS REQUIRED?
PLATTED LOT?
❑ ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
❑ YES ❑ NO
BASIC PLAN?
❑ YES
❑ NO
CHANGE OF USE?
❑ YES
o NO
❑ YES ❑ NO
UP/SEPA/SU?
❑ YES
❑ NO
❑ YES ❑ NO
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
Bulletin # 100 — March 30, 2004 Page 2 of 4 k\Handouts — Revised\Permit Application