05-106561 4!
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Federal Way
PERMIT
COMMUNIIYDEVELDPMEM SERVf c P L 1 t IT SF MF CO ME EL PL DE EN FP
33325
FEDERAL WAY,W98063-9718 ° P P LI C AT I O N TD
253-835-2607•FAX 2$3-8
www.dIuofederalwau OF FEDERAL WAY
BUILDING DEPS',
The ollowi • is re•aired in ormation-an Inco •tete a••lication will not be acce• - d. Please •rint le•ibl in in or • .
• ;TY INFORMATION
SITE ADDRESS �5 � � 1/a- SUITE/UNIT#
/
ASSESSOR'S TAX/PARCEL# a. log - efd 4( LOT SIZE(sj)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal deswipeon)
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING XFIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
C6,µp L. tJ 6 w 1'c.rks A-LA-1 ,S'r'.-r 4- 4- 64 P-t v
/ I o nff--6 V-t e•1&-- A-r✓b 1 2.GE J S P P 2 G:ss I ON, •S Ys TEtils g L E)s hu6-
CAt_I_ r'-I E-CHAAri c A L 13 or/+e oa s) —r✓- t s E ,tT.) c s-r'!NG-- A4D a02.6SS'At3`
PROJECT NAME(Name of Business or Owner Last Name) (L`� HAUS&12..- R Lb(, I 1.1 o f+
PEOPLE INFORMATION
PROPERTY NAME
Q PRIMARY PHONE
OWNER Ca-4Ai)esErz.
MAILING ADDRESS CITY,STATE,ZIP -
C�D, &O}( 4 717 (.4.44 98'063.
.
CONTRACTOR COMPANY NAME APPLICANT NAME
OFFICE PHONE
rE DER/1-i- Fl( .s F ry t N C., ROGER. t 13,642 K ('as") 6 7O -
MAILING ADDRESS / CITY,STATE,ZIP CELL PHONE
itIt2:31 36TH-Ave S Surr8.loa 1-1(4hawooi, 1444 ?tO% (36o ).. &plc - 376 7
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
B L ( a5' ) 670 1,2675
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
/ /
APPLICANT COMPANY NAME APPLICANT NAME
OFFICE PHONE
(
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
RELATIONSHIP TO PROJECT FAX NUMBER
o Architect o Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT NAMER o� PRIMARY PHONE E-MAIL ADDRESS`� . BA Rc
'` `n� ( 425) - a-741-9 v-vger �- ire,cow
LENDER � :ura � Fol;-�. rY' ;,knt,t~r_ 417 t, NAME
MAILING ADDRESS CITY,STATE,ZIP
■ DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 36, 0
SPRINKLERED BUILDING? o YES a NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? a YES a NO
WATER SERVICE PROVIDER a LAKEHAVEN a HIGIIZINE 0 TACOMA O PRIVATE(WELL)
SEWER SERVICE PROVIDER a LAKEHAVEN a HIGHLINE 0 PRIVATE(SEPTIC)
I
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
•
ADDITIONAL FLOORS(DESCRIBE) •
DECK(COVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS 6MS WO PROPOSED TOTN. 4 t�v_.t•t,j r ,R Xc Roeoseo br a v sr
**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. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
•
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commerda) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(orThb/Shower Combo( SHOWERS WATER CLOSETS
(Niles MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sham) 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 f sled 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 a-IC— g 5Z7' lam* 44-t- t DATE jol-r a 4?/05s
(Signature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑Agent XContractor ❑Architect 0 Other
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Bulletin#100—January 7,2005 Page 2 of 4 k\HandoutsTermit Application