04-102255 Hof�'� 'l _ J C) ;L 2 �._
Federal Way v PERMIT.
COMMUNITY DEVELOPMEN•SERVICEyg''��S'E - SF MF CO ME EL PL DE EN FP
33530 FIRST WAY SOUTH•PO BOX 9718 P P L I CATION
FEDERAL WAY,WA 98063-9778 TD / /
253-6614115•FAX 25366/4 J U N 0 129 7
www.dfuo federulwau.com
The oilowin• is re;wii► 4 . (,•Bias AthltYincow•lete a..lication will not be acce.ted. Please .tint le•ibl (in ink)or -.
PROPERTY INFORMATION
SITE ADDRESS .3 /4/`J 6 ,- 4 C- _ SUITE/UNIT# '—'—
ASSESSOR'S TAX/PARCEL# O `J ,2 / Q c - `V' Al LOT f)
SIZE(s
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) re;--/3(✓tQA(. /► " /44-1:A65r r at T`IC4,24
(Attach separate page for lengthy legal desvipcon)
PROJECT INFORMATION
TYPE OF PERMIT o B IC•ING ❑ PLUMBING ❑ MECHANICAL WI ' Us7`'> /�1;e Li a-
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING❑ FIRE PREVENTION SYSTEM
PROJECT D CRIPTION(Provide4etailed description of work included on this permit onlli)
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PROJECT NAME(Name of Business or Owner Last .me) //-V E✓7ev4'C 6(9i ' //c?.4--6.5•771-i /✓4-re A-1e L
PEOPLE INFORMATION
PROPERTY NAME _ - PRIMARY PHONE
OWNER /.ej 2A L IA. /4'47- Sr polo` pis rie iCT ( ) -
MAILING ADDRESS CITY,STATE,ZIP
3)ya /el- A✓t S r 1_ .1 Y i U.2 4. 9 BoO 3
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
n sic (�'h.-)r. 1A3 c_ k/fy15') SG j - 38.5.2
M ILING ADDRESS 1 CITY,STATE,ZIP CELL PHONE
/ti 9s9 rye 9s'-L <7 12-1rc0-N n 1,04- 9e 5)- (`,9S ) R6J- 'S S/
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER /EXPIRATION DATE FAX NUMBER
(I-el 4-4 6 a 12 (o O- B L /9- 13i igeo4 (1 - & '/ - &
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
a S_ S. & c / a 9 2 4- P c36i C i i�ooS
APPLICANT COMP NY NAME APPLICANT NAME OFFICE PHONE
z 5� (�Sj-, .vC - (_h2iS (/Asi R6 5 - 7V.5 .Z
AILING ADDRESS CITY,STATE,ZIP CELL PHONE
/4/9S' NC. �93— Si vHorlo) 14-19. 9gds--,z (yzs) g qq- es's/
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect ❑ Tenant ❑Agent l r er(Describe)`yg1J• CcjA , (q 5 ) V) - .1-,3'3.--
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
�o.rt we uc E,O (t*oC ) ' s"- 95 6 o
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 nil" j'CA-k-t PROPOSED USE ik. Y .'
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ `IOC,,
I
SPRINKLERED BUILDING? 'FES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/• • .1 RED? �[T'AO
WATER SERVICE PROVIDER HAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER p—ItEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING SQ.FT. PROPOSED SQ. FT. TOTAL
BASEMENT
FIRST
SECOND -
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS? OTAL EXIST TOTAL PROPOSED TOTAL EXISTING AND PROPOSED
"NEW HOMES ONLY" NUMBER OF BEDROOMS MATED SELLING PRICE
FIXTURES
Indicate number of each type of fixture to be ins ; led or relocated as part . this project. Do not includeµ existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOG REFRIG.SYSTEMS
BBQS FANS HOODS(Comm 6iO4 WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEA RS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS or Tub/Shower Combo) SHOWERS WATER CLOSETS(rode) MISC(Describe)
DISHWA ERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sinks) ACUUM BREAKERS ELECTRIC WATER HEATERS
I
DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the i t o •ation 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 any person, including the undersigned, and filed against the City of Federal Way,but only where such claim
arises out of the reliance oft cit , i in • officers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE DATE 06
ignature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent actor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
o NEW o ADDITION o ALTERATION ❑ REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES ❑NO
ZONING DESIGNATION CHANGE OF USE? o YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? o YES o NO
Bulletin#100—March 30,2004 Page 2 of 4 k\1landouts—Revised\Permit Application