05-105915RECEIVED _
Federal way PERMIT NOV 1 6 Z00p
COMMUNITYDEVELOPMENTSERVICES SF MF CO ME EL PL DE
33325 D AVENUE SOUTH • BOX 9778 A P P L I C ATi ` EDERAL
FEDERAL 0 Y, X 98063-9718 -260 ING DE /
253 -835 -2607• FAX 253- 835 -2609
au w.dtuo(federatwa u. CORI
The followina is required information - an incomviete avnlication will not be accented. Please vrint ieaiblu /in ink) or t
SITE ADDRESS ;5M (S l "-'- \41 c`. -)Y fl SUITE /UNIT tt / 0 (a
ASSESSOR'S TAX /PARCEL S J - SLOT SIZZEE (sf)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) N`Q;�l�"• �1�1 l� i ✓� 1 °T ���
(Aft -h sspmnte page jor lengthy 1e9a1 de pHon)
PROJECT • •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION LECTRICAL. ❑ ENGINEERIN FI PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description o work included on this permit onl
f n u)
ItnS'1� (I � �-®r _� �� c�.Q.Y�, 2 �orV► � �-�o►�S
PROJECT NAME (Name of Business or Owner Last Name( �-'e W (X I"JU <<�1 - eyw `Tl kb
PEOPLE •- •
PROPERTY NAME { p Kt� (� �y PRIMARY PHONE2 1
OWNER 9 r `e � V�� 1 l ' �s f 0 ((d (KA QA Y)5-,)3 - �1 ,01 1
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
MAILINU ADDIIE85 CITY, STATE, ZIP
COMPANY NAME
APPLICANT NAME -
OFFICE PHONE
h(o
0 C
va* eko
(2,0 10)
MAILING ADD SS
-
C17Y,.STATE, ZIP
CELL PHONE
17-513 S
Statn -e, W v',,
-
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
)`�'jz
_-
H L
CONTRACTOR'S REGISTRATION NUMBER 1copy of card required with each application)
EXPIRATION DATE
W A5 ii z 'k °i2
e ZCI
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ I I ✓�'1 ' VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
F
I
AREA DESCRIPTION
EXISTING
PROPOSED
S , FT.
TOTAL
S . FT.
BASEMENT
o NEW o ADDITION,, o ALTERATION
o REPAIR o TENANT IMPROVEMENT
FIRST
BASIC PLAN?'
❑ YES
SECOND
ZONING DESIGNATION
CHANGE OF USE?
THIRD
o NO
NEW ADDRESS REQUIRED? ❑ YES o NO
FOURTH
❑ YES
❑ NO
PLATTED LOT? o YES o NO
ADDITIONAL FLOORS (DESCRIBE)
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
DECK (COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
snsr °o
rsorosso
TOTAL
mrAI.maxaaar ,
ToTALlIC9"Wo
roTAt u,, '
"NEWHOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
Value of Mechanical Work $
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS for Tub /Shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS )Bathroom Sinkal
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS )commerriall
RANGES
GAS WATER HEATERS
WATER CLOSETS (roilet) _
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
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 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 a part of
this application. /
NAME /TITLE WA11 �A � 1 DATE 1' u/I VD5
(Signature) (Title(
RELATIONSHIP TO PROJECT []Owner ❑ Agent contractor ❑ Architect ❑ Other
Bulletin #100 — January 7, 2005 Page 2 of 4 k \Handouts\Permit Application
o NEW o ADDITION,, o ALTERATION
o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES ❑ NO
BASIC PLAN?'
❑ YES
a NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
o NO
NEW ADDRESS REQUIRED? ❑ YES o NO
UP /$EPA /SU ?-
❑ YES
❑ NO
PLATTED LOT? o YES o NO
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
Bulletin #100 — January 7, 2005 Page 2 of 4 k \Handouts\Permit Application