05-106437 an of
RECEIVE . -Federal Way PERMIT _
3fooMMUNI7YDEVELOPMEM'sERVI �y SFC)O ME EL PL DE EN FP
2 1 AVENUE SO PM •PO BOX:0E C 2j Q 20 ,v
FEDERAL60�WAY, z RPPLICATJON ' �L
'""""'':1 " "ITY OF FEDERAL WAY / '� /�6)
The ollowi • is re.u�ita n�oPmDa on-an inco •fete a••lication will not be acce•ted. Please .rint le•ibi in i or
PROPERTY INFORMATION
S op u RESWir (S—
SUITE/UNIT#
A OR'S _ _ LOT SIZE(sf)
1Piii
L J_AliION e.g.A e .f� ,Loll)
U .PROJECT ia.r uzu. TION
TYPE OF PERMIT /14
UILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESC� CRIPTITI((Provide tailed_description o work include on this erm't onl .�f. i t�1 k-v.. :.D�. 4A. �.�,_. ► .Y �hIK I (JCII�.I
> i
I IZS VIZ_ten- 1_ Z. Sl r
PROJECT NAME(Name of Business or Owner Last Nam- j SQ S C. At Q
■ PEOPLE INFORtvui,.....
PROPERTY N r- 'I ) �� PRIMARY PHONE
OWNER h (C r ea (7 60 )60 7-o27Q-D
MAILING ADDRESS CITY, AT ,ZIP
152_5 u�t i i ue � -- , . efkao V
CONTRACTOR r-9QdPANY NAME /�7l .��� APPLICANT NAME OFFICE PHONE _
4V ii". V-a..4 4.0
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
Z 5 S.,. 5r"� "TeKc, u3A 9Syb Z53)
' CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER — � �
EXPIRATION DATE - 'FAX NUMBER
Z0-.05-Lb.S�1. -B L /z /31 /65 )y7t( -4ZzZ
NTRACTORS REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
APPLICANT c-"trOMPANY ME pejo
AP CANT NAME OFFICE PHONE _
`IVO Q a noo �4Vt 4' sb-t _ . - (425146z z770 .
MAILING ADDR S _( ATE,ZIP
120 t J IPPe"- S .St,, Z c�� iv we WA, 5g 5as CELL PHONE
)N 777 - 7 Oo
RELATIONSH TO PROJECT
FAX NUMBER
a Architect ❑Tenant ❑Agent ❑ Other(Describe) (Z53)g3q - !L,�` 7
CONTACT NAME�J`� PRIMARY PHONE E-MAILADDRF_S$ 'J-.-�Dt._
sue, (2S3 rr?7 - 7cj0 Sfriara,, Pro n l4
LENDER NAME �� •rr f•.,,'-•fi r.i ,f,(.' °4' -, ,{,Xa-X kj,T-ir..X4aa
MAILING ADDRESS CITY,STATE,ZIP
I
• ■ DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
��
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ . �
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? a YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA a PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
•
- PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
•
BASEMENT
FIRST
SECOND
THIRDIli ... 1; .
; 4
t
FOURTH ..
'F z • • [ _
A s a •• s y�/i If Tr i
DECK(COVERED?) A. ( 4. -- } 4.,,,,„„, .t
GARAGE 0 CARPORT 0
�1
EXISTIRO PROPOSED TOTAL Sy t ,°3__-• R..:a.-Ve R... ED ►r, , AL IIF
NUMBER OF FLOORS . `,a. : -.
**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(commercial) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES OAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or7ub/shower combo( SHOWERS WATER CLOSETS crones MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAYS(ea[hroomSinks) 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 ncluding costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claim),which may be made by any hiding the undersigned,and filed against the City of Federal Way,but only where such claim
arises out of the reliance of the ci officers and employees,upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE DATE G' VCR
(Signatu (Title)
RELATIONSHIP TO PROJECT ❑ Owner"(Agent ❑ Contractor ❑ Architect ❑ Other
@?l',lt '( l D/:4.kr .e ,.
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Bulletin#100-January 7,2005 Page 2 of 4 k\Handouts\Permit Application