05-105626A, \`a V4 RECEIVED
Cn'Y GF A L*_ i S � �__C; � (- "
Federal way PERMIT Nov 0 a 20
�FMFCOMEELPLDEE P
COMMUNITY DEVELOPMENT SERVICES
•33325 FEDERAL AVENUE SOUTH . 63 971 9778 A P P L I C A T' F AY
-2607- X 98063 -260 E D E RAL
253- 835- 2607•FAX253- 835 -2609 ING DEPT
unuw. atuoffederalwa
The ollowin ink) I t
PROPERTY • •
SITE ADDRESS . SUITE /UNIT #
ASSESSOR'S TAX /PARCEL # 0 d C) - 3 m - LOT SIZE (sj
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for lengthy legal descnptionl
PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only
0
PROJECT NAME .(Name of Business or Owner Last Name) _ �� U WY �S V 1
PEOPLE •- •
PROPERTY
PRIMARY PHONE
OWNER T I E E L t• (
CONTRACTOR
APPLICANT
CONTACT
LENDER
W C�'� I v -'i T I �.•.
) -
MAILING ADDRESS
2333 C-AR -SLOW �1
CITY, STATE, ZIP
KIa le, L1N6 WA gC303)
COMPANY NAME
Rk\tc M -kA of �
APPLICANT NAME
+-_\Rn ��z
OFFICE PHONE iv
aag
MXILING DRESS
CITY, STATE, ZIP
CELL PHONE
jITY /]O FE,ryERAL AY BUlS�I E S LICENSE NUM�B(ER -EXPIRATION DATE
� �3 B L � � �!�� / � �
FAX NUMJB 1 e �7�
(356)4a � - lX.,"�.zl
CONTRACTOR'S REGISTRATION NUMBER copy of card required with each application) EXPIRATION DATE
COMPANY NAME
AV
APPLICANT NAME
OFFICE PHONE
MAILING E
,STATE, ZIP
41
CELL PHONE -
LA O SHI TOPROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
-
PRIMARY P NE -
AAA Q
E -MAIL ADDRESS
�+erRCW'9,27 09S Lender i Lion {s
regrl{reYt:ijprojec$'xvaEfue tcicceet(s $SbiDO<
NAME
MAILING ADDRESS
CITY, STATE, ZIP
EXISTING USE N PROPOSED USE RQ5Tk)" K
EXISTING ASSESSED /APPRAISED VALUE $ . VALUE OF PROPOSED WORK $ Z 1 6 1 f
SPRINKLERED BUILDING? �LAKEHAVEN !1.YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? iYES ❑ NO
WATER SERVICE PROVIDER ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER LAKEHAVEN 13 HIGHLINE ❑ PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
SQ. FT.
PROPOSED
s . i r.
TOTAL
s . FT.
ASEMENT
p'YES NO
BASIC:,PLAN , . ,:,,c =4:XE3,
FIRST
Z q 7
I
---
--
SECOND
O
NEW ADDRESS REQUIRED?
❑YES NO
THIRD
UP /SEPA /'SU? ❑YES ''-
" 0 is
PI:ATTED:LOT?
FOURTH
MEMO PERMITREQUIRED? ❑:YES
;NO"
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
BRISTING
PROPOSED
TOTAL
:. ^. TOTALZEISTING'SF
� TOTAL PROP = OF,
TOTAL SF
* "NEWHOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or Tub /shower combo
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
to be installed or relocated as part of this project. Do not
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (commercial)
RANGES
GAS WATER HEATERS
existing fixtures to
WATER CLOSETS rroiiey _
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I cert#fy 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 filed 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 apart of
this application.
NAME /TITLE �' DATE \JI y 1 1
(19141 (Title) 1
RELATIONSHIP TO PROJECT Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
-o NEW ❑•ADDITION
c ALTERATION
❑ REPAIR •o",TENANTIMPROVEMENT
BUILDING SHELL; ONLY?
p'YES NO
BASIC:,PLAN , . ,:,,c =4:XE3,
BA.-
.:ZONINGMESIGNATION
:CHANGE;OF2USE? .. ; - =o`YES '
O
NEW ADDRESS REQUIRED?
❑YES NO
UP /SEPA /'SU? ❑YES ''-
" 0 is
PI:ATTED:LOT?
' `YES ❑i$0
MEMO PERMITREQUIRED? ❑:YES
;NO"
Bulletin #100 — August 19, 2004
Page 2 of
k \Handouts\Permit Application