05-105067CITY OF
Federal Way
COMMUNITY DEVELOPMENT SERVICES
33325 8- AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, WA 98063 -9718
253- 835- 2607•FAX 253 - 835 -2609
wmv.xi(yoffederalway, —
SITE ADDRESS 5 50c)
PSCEIVED
-0-5 -10 5 -0-�4
P ERMI Q 2005 SF MF CO ME EL PL DE E FP
APPLICA� oEP WA T.
ion - an incomplete application will not be accevted. Please print leaiblu (in ink) or tune.
S.
SUITE /UNIT #
ASSESSOR'S TAX /PARCEL # p- LOT SIZE (sfl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) A i ` ff"C -o
(Attach _separate page for Ieagthy legal descrtptloa)
• T-7 m ?17,71 •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
ii 57 /64-�, c -� cr /�t'ld— e,Ss'�iA , 1--Ile- 111/1 � ..�t/3, . !)'t` /✓1
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE • •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME
!`
PPjNjARY PHONE�
MAILING
5
CI . STATE, ZIP
eIVS
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
COMPANY NAME
R- C -A�-,e Vi .e. ��cur�
jv.�.
APPLICANT N E
✓. u5
OFFICE PHONE
(aV6 )7.?1- - 5,?1'7
MAILING ADDRESS
n
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
CITY, STATE /, ZIP !
/
CELL PHONE
CI y,$IJ ICi� $fit �� EXPIRATION DATE
s L i.� 3/ /os
FAX NUMBER
�a�6 )'7l -t3C6o
CONTRACTO
AAR'S REGISTRATION -•NUMBER (copy, of card card i/g b'" WW4..,sa"
EXPIRATI N DATE
C MPANY AME
AP ICANT NAME
OFFICE PHONE
�j✓
MAILING ADDRESS
CITY, STATE, ZIP
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
NW PRIMARY PHONE E -MAIL ADDRESS
4.c'� u �/ ) 8 1 W4 v,c( S Z
Per RCW 19.27.095: ' Lender igformation is
NAME
required ifproject value exc�
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ e VALUE OF PROPOSED WORK $ -i I i , SGo
SPRINKLERED BUILDING? q.YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES 710 NO
V
WATER SERVICE PROVIDER
SEWER SERVICE PROVIDER
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
2d6.
$'161'.40
Y �
GTY QP
Federal Way
COMMUNITY DEVELOPMENT SERVICES
33325 8- AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, WA 98063 -9718
253 - 835 -2607• FAX 253 - 835 -2609
W W W- dty09j deratway —
SITE ADDRESS 556c)
Uc)
ASSESSOR'S TAX /PARCEL #
10
N
VED —0-5 -1 -0 5
CO ERMIMP 3 o Zoos
SF MF O ME EL PL DE E FP
APPLI CA RAL WA �° –
I I NG DEPT,
:on - an incomplete application will not be accepted. Please Print leaiblu (in ink) or tupe.
S.
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) Z A • ` ' `K� 5J
(Allaeh sepm ate page,(or leaglhy legal descnphoN
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
SUITE /UNIT #
LOT SIZE (sf)
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onl
�' u) _
• —1
of Aclel-e6sA,46
PROJECT NAME (Name of Business or Owner Last Name) Z-4 g`Ixef
PEOPLE I • •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
NAME ��r
P PHONE
(Lftct
MAILING ADDRESS
� 5
CI , STATE, ZIP
4/
COMPANY NAME _
APPLICANT N E (
�Jw'tc!• lJSTcCC
(OF�FIICE PHONE a q
�v6 ) %d'd�- - �t)l I
MAILING AD/,�pRESS
CITY, STATE,, ZIP
Ai G
CELL PHONE
CELL
"" 4 EXPIRATION DATE
FAX NUMBER
CONTRACTOR'S REGISTRATION NUMBER lepPy of card •"quad W104. 0aeh,.4WUe4bWk1F. EXPIRATI N DATE
PA L1 f-F S -V1 3 OLk /
A MPANY AMEN!
f "r /C t�"7+�1! t'GC/ ✓I'` �s�C •
AP ICANT NAM
V L
OFFICE PHONE
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
N
PRIMARY PHONE
-
E -MAIL ADDRESS
�A "'(
Per RCW 23..27.095: Lender information is NAME
required if project value excee
MAILING ADDRESS CITY, STATE, ZIP PHONE
EXISTING USE I lVTZIA 1 / ( PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ ` VALUE OF PROPOSED WORK $ 3 A "1 ( S:00
SPRINKLERED BUILDING? 4-YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES r❑ NO
V
WATER SERVICE PROVIDER ALAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER WL4KEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
0,& -
F
,r 1
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FIRST
gpee w
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
MST@iG
PROPOSED
TOTAL
TOTAL Mgr]VG SF
TOTALPROPOSM SP
TOTCALSF
* *NEW HOMES ONLY ** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate nu of each type of fixture to be installed or relocated as part of this project. Do not
MECHANICAL c
Value of Mechanical Work $_
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or Tnb er combo)
DIS'
GAS OUTLETS
SHING MACHINES
LAYS (Bathroom Sinks)
EVAP E COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS TLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS J/'�
�(commeroiai)
RANGES
GAS WATER HEATERS
WATER CLOSETS
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
to remain.
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. Q
NAME /TITLE qJ l DATE / - 3&-0 S
(Signature (,ntie)
RELATIONSHIP TO PROJECT Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 — January 7, 2005 Page 2 of 4 k\Handouts\Permit Application