03-104732RECEIVED
OCT 1 6 1CONSTRUCTION PERMIT APPLICATION
CITY OF --� 0� APPLICATION NUMBER: � - E
Federal Way CITY OF FEDERAL WA rAPPLICATION NUMBER: _ _ - _ _ _ _ _ _ _
BUILDING DEPT APPLICATION NUMBER: -
**The following is required information — Please print (in ink) or type**
Please note: Electrical, Fire Prevention Systems and Engineering permits may require a separate application.
PROPERTY•. •
S . f �- -
SITE ADDRESS: ASSESSOR'S TAX/PARCEL #: _ � � _ _ _ _ _ _ _
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
■ PROJECT INFORMATION
TYPE OF PROJECT (This application): ❑ BUILDING ❑ PLUMBING MECHANXCAL ❑ DEMOLITION
In ELECTRICAL ❑ ENGINEERING iI E PREVENTION SYSTEM
PROJECT NAME: l I J 6
PROJECT•• •
PROPERTY OWNER:
CONTRACTOR:
APPLICANT:
CONTACT PERSON
NAME: DAYTIME PHONE:
MAILING ADDRESS (STREET ADDRESS; CITY, STATE, ZIP):
NT.1',�,�r
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�AY[l� M € PNON}E:
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MAPNUDOR S (SCREEI ADDRESS, �� �C
ATE, ZIP);
EVENING PHONE: _
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
Iti - �y
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PAX NUMB : + _
l/EXPI DATE:
CONTRACTOR'S REGISTRATION NUMBER:
CO q Li
TION
(copy of card required)
NA E:
V 1 ,
DAYTIME PHONE:
MAIJ,ING A DRESS (STREET ADDREI `, ICITY� � , ZIP :
11�iJJ
f,
(jo
fm
EVENINd PHONE:
fJ _
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RELATIONSHIP TO PROJECT:
❑ ARCHITECT ❑ TENANT
OTHER ( DESCRIBE):
FAX NUMBER: O
[C }L
'OR THIS PROJECT: ❑ PROPERTY OWNER ❑ APPLICANT
❑ CONTRACTOR
E-MAIL ADDRESS:
16C� U0yo 6 •�I��
EXISTING USE: _ 14 It 11 4( 1� L EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
PROPOSED USE: 1hwi A A PROPOSED VALUATION FOR IMPROVEMENTS: 1W t00
SPRINKLERED BUILDING? RYES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: ❑ YES ❑ NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
"NEW RESIDENTIAL CONSTRUCTION ONLY"
NUMBER OF BEDROOMS:
ESTIMATED SELLING PRICE:
PROJECT FLOOR AREAS I
FLOOR
EXISTING SO. FT.
PROPOSED S . FT.
TOTAL
BASEMENT-. --
FIRST
SECOND
THIRD
_
FOURTH
OTHER FLOORS (DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S)
GAS LOG(S)
REFRIG. SYSTEM(S)
BBQ(S)
FAN(S)
HOOD(S)
WOODSTOVE(S)
BOILERS)
FIREPLACE INSERT(S)
RANGE(S)
MISC. { }
COMPRESSOR(S)
FURNACE(S)
DUCT(S)
GAS PIPE OUTLET(S) HEAT SOURCE::❑ ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S)
LAVATORY(S)
URINAL(S)
WATER HEATER(S)
DISHWASHER(S)
RAIN WATER SYS.
VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S)
WASH MACHINE OUTLET
GAS PIPE OUTLET(S)
SINKS)
WATER CLOSET(S)
MISC. ( )
INTERCEPTOR(S)
SUMP(S)
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 attorneysfees incurred in the
investigation and defense of such claim), which may be made by any person, including the undersigned, and fled 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.
NAME/TITLE:
❑ PROPERTY OWNER PPLICANT ❑ CONTRACTOR
FnR nFFTrF 1 icF nmi Y.
DATE: 10
❑ NEW ❑ ADDITION ❑ ALTERATION n REPAIR ❑ TENANT IMPROVEMENT
CENSUS CODE:
LOT SIZE:
ZONING DESIGNATION:
BUILDING SHELL ONLY? ❑ YES ❑ NO
COMP PLAN DESIGNATION
BASIC PLAN? ❑ YES ❑ NO
SECTION TOWNSHIP RANGE
NEW ADDRESS RE UIRED? ❑ YES ❑ NO
PLATTED LOT? ❑ YES ❑ NO
CHANGE OF USE? ❑ YES E; NO
COMMUNITY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063-9718 • 253-661-4000 • FAX: 253-661-4129
www. i offe4 lway�-Cm