05-105908RECEIVED /
Federal Way
wOV j e 2m PERMIT SF MF CO ME EL PL DE FP
COMMUNITY DEVELOPMENT SERVICES
33325 8TH AVENUE SOUTH • 63 BOX
FEDERAL WAY, 98063-97CITY OF FEUE
R L I C A T I O N
253-835-21607, X 253-835-26 09
u %u•tHt Lgderalway cm DUILDWG DEPT. _ 4or
D / /
The followina is re uired information - an incoLnj2lete geelication will not be accg ed. Please rant le ibl in inkj or
M PROPERTY INFORMATION
SITE ADDRESS J %� �`-� 1 Y ���3 �V 1 _ SUITE /UNIT # /0 D
ASSESSOR'S TAX /PARCEL # _ - LOT �SIZE (sf)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attdch separate page for lengthy legal description)
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITIO ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME
V\ o
(� V
MAILING ADDRESS
OWS--)3 MARY PHONE
- Z(�
MAILINU ADDRESS
_ �� ti��
ITY, STATE, ZIP
LIY k i V iLI " Lpv t P" ei &
t �
COMPANY NAME
APPLICANT NAME
We OW
OFFICE PHONE
GlW(M h
fns
MAILING ADDREU
( ?,53 S 34 U;SDh
Sr
crrY, STATE, ZIP
JYU ^ a gi
CELL PHONE
( )
-
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
-1
(P) 3 U,
B
L
CONTRACTORS REGISTRATION NUMBER (copy of card required with each application)
EXPIRATION
DATE
�Q�2-
-1 Z
a
COMPANY NAME
APPLICANT NAME
1iza lu
OFFICE PHONE
(lib) �
- 32�s
Mcolmlah Y7r)
wti-
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
G S Vkllat
w A-
( )
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant
❑ Agent o Other (Describe)
NAME
Vu o tztl om
1
PRIMARY PHONE
( '-wo acs- - �3,,Wr
E -MAIL ADDRESS
PS1O RCW 29:27;095: 'Lender information is
required if project project value exceeds $5,000
NAME
MAILING ADDRESS
CITY, STATE, ZIP
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ 21 100/y • 6D 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 o HIGHLINE o PRIVATE (SEPTIC)
4 �
AREA DESCRIPTION
EXISTING
SO. FT.
PROPOSED
S . FT.
TOTAL
SO. FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
=MUG
PROPOSED
TOTAL
TOTALE7OSTMSP
TOTALPROrom OF
TOTAL SP
* *NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to
Value of Mechanical Work $
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or Tub / shower combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Bathroom sink.)
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (commercial)
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 { �A t1` \�w DATE 1 1 S
(Signature) a (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent )(Contractor ❑ Architect ❑ Other
Bulletin #100 — January 7, 2005 Page 2 of 4 k \Handouts\Permit Application