06-102360---r A R,ECEIV� �3 06-4-ozzlo-
Federal way PERMIT
COMMUNITY DEVELOPMENT SERVICES 'A rt� 2 SF MF CO ME EL PL DE Eli
33325 FEDERAL SOUTH • 63 BOX 971 MAY CATI O N
FEDERAL WAY, FAX 93063 -260
253 -835 -2607• FAX 253 -835 -2609
RS1P1iLCliift7f {Ct2`4 ?rQhiKti(. Ct7Ri CITY OF FEDERAL
BUILDIN4 DEPT,
The followina is reauired information - an incomplete application will not be accepted. Please print legibly fin ink) or type.
SITE ADDRESS ✓ � t 7 �K C Gy� T `T' ` �� SUITE/UNIT
ASSESSOR'S TAX /PARCEL # -2, Q T v LOT SIZE (sfi
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach sep—W page f- Lengthy Legal de- c W ianl
PROJECT •' •
TYPE OF PERMIT
i
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
Zns)I("\k 'S hell V;ce S �e^"'
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
N
J
NAME PRIMARY PHONE
N-S MW L LC, ( Hzs) 1-16, - 2-7no
MAILING ADDRESS CITY, STATE, ZIP
915 118"" .� ile nee _Sir Set l e v u.e U lk ')SW-s:
COMPANY NAME
APPLICANT NAME
i..o �OC,��Zrc
OFFICE PHONE
( ) -
APPLICANT NAME
OFFICE PHONE
c'Ak a�
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
&4D )'Ot- 1hL'ic
(Z5 ) �1�6 LZold
MAILING ADDRESS
(� PRIMARY �) HONE
ADDRESS
CITY, STATE, ZIP
CELL PHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
v_ I �-B
/ZEE
6ls
_�
L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application)
EXPIRATION DATE
a
COM�jPAN\Y NAME \'� `
ia\ 7�ILV F 1C2. C C�t� ✓��a?\
APPLICANT NAME
i..o �OC,��Zrc
OFFICE PHONE
( ) -
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
NAME W✓ �O`�S�C�,C�,y
(� PRIMARY �) HONE
ADDRESS
Per RCW 19.27.095: Lender; irtforMation is ` -,
NAME
required }f project value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED / APPRAISED VALUE $ /
SPRINKLERED BUILDING? �`7 YES ❑ NO
WATER SERVICE PROVIDER LM LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVEN
PROPOSED USE
�„ 1
VALUE OF PROPOSED WORK $
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE ❑ PRIVATE (SEPTIC)
0
AREA DESCRIPTION
EXISTING
FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
EVAPORATIVE COOLERS
BBQS
FANS
FIRST
FIREPLACE INSERTS
COMPRESSORS
FURNACES
SECOND
GAS PIPE OUTLETS
❑ YES
- ❑ NO
THIRD
❑ YES ❑ NO
UP /SEPA /SU?
FOURTH
❑ NO
PLATTED LOT?
❑ YES ❑ NO
ADDITIONAL FLOORS (DESCRIBE)
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
DECK (COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
ea SSG
wtoeosen
TOTAL
TOTAL RusrWGsR
TOTAL PROPOSED W
TOTALap
**NEW HOMES 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.
MECHANICAL
SHOWERS
Value of Mechanical Work $
SINKS
AIR HANDLING UNITS
EVAPORATIVE COOLERS
BBQS
FANS
BOILERS
FIREPLACE INSERTS
COMPRESSORS
FURNACES
DUCTS
GAS PIPE OUTLETS
BATHTUBS (or 7116 /Shower Combo(
SHOWERS
DISHWASHERS
SINKS
GAS PIPE OUTLETS
SUMPS
WASHING MACHINES
URINALS
LAVS (Bathroom Sinks(
VACUUM BREAKERS
GAS LOGS
HOODS (Commemiap
RANGES
GAS WATER HEATERS
WATER CLOSETS froilet)
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 a part of
this application.
NAME/TITLE 1&6 �a� a��c. �iL� LL� 1 11 a �c i � � DATE
(Signature ( �T
RELATIONSHIP TO PROJECT Owner ❑ Agent Contractor ❑ Architect ❑ Other
❑ NEW ❑ ADDITION
o ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHILL ONLY?
❑ YES ❑ NO
BASIC PLAN?
❑'YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE?
❑ YES
- ❑ NO
NEW ADDRESS REQUIRED?
❑ YES ❑ NO
UP /SEPA /SU?
❑ YES
❑ NO
PLATTED LOT?
❑ YES ❑ NO
DEMO PERMIT REQUIRED?
❑ YES
❑ NO
Bulletin #100 — January 7, 2005 Page 2 of 4 k \Handouts\Permit Application