06-102556r
J
SECEIVED
Federal MAY 19 zon 069- L (/
er fty PERMIT
COMMUNITY DEVELOPMENT SERVICES T FEpERpLV1 MF CO ME EL PL DE EN FP
33325 D AVENUE SOUTH • PO BOX 9778 /• T � T I /• 1� 5 pEpT
FEDERAL 07 WAY, WA -FAX 980&3-260 .L/, P L A 'T'T'V�VJING
253 - 835 -2607• FAX 253.835 -2609
urww. citooffederalwati. co
The following is required information - an incom fete application will not be acce led. Please i2rint le ibl (in ink) or
PROPERTY • •
SITE ADDRESS .Q SC 1.1 N 3LIL111t WA-/ SUITE /UNIT # ISO
ASSESSOR'S TAR /PARCEL ; - 9 LOT SIZE (sfi
LEGAL DESCRIPTION (e.g. Acme Estates, Lot :O
(Attach separate pagefw lerDttuj legal descriptiorO
PROJECT • ' •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING It FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
MoQLFy PjTS 1L)C, EZ2E AL,A(LM, 2 FA`ZM`2S
1 l2S(► 2Ailt�CF G (ZLL,LP _VC Iu AKYT �:t rn PRyuGaick_j -T
PROJECT NAME (Name of Bw;iness or Owner Last Name) F A(2- ,l 2 A kg E Cx' (z() 4 L f?
PEOPLE • •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME
I�GDr -O2D i? vPC: Z- 70L)v %o%Ls
PRIMARY PHONE
N
MAILING-ADDRESS H
CITY, STATE, ZIP
L9 SiA� 39� SS 2 5S
{�G u'TV1J �cosS
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
F 5 tkAfZC, SMWmS LLG
ROO M A wAILD
(�3) 84to - S �i0a
MAILING ADDRESS
w0 :3vx 731 �20
CITY, STATE, ZIP
PuVALLuP, tjA 9637
CELL PHONE
(6953) GS 1 - at,oq
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
-0 0- - -Qj a -i C - ,a 8 L-B
(DS-3) XLI& - S40q
L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
ESQ (A efiLILj6K I /09
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
C S UARE"� � JT L
1R M \ "A (Z
Q:S3 ) 8 Y, - S4.('t�
MAILING ,ADDRESS CITY, STATE, ZIP
?v. ( Z2--) t p Lori S 373
CELT. PHONE
(d53) &5t - �LaUoi
RELATIONSHTP TO PROJECT 10
❑ Architect ❑ Tenant 14 Agent m Other (Describe) S4tB CUNi KAe-w
FAX NUMBER _
( -is 3)
NAME
C, 1_) 1Y1 jfj tk( j0
PRIMARY PHONE
(2<3 ) - 5LI O
E -MAIL ADDRESS
Per RCW 19.27.095: Lender information is
NAME
required ifpmject:value exceeds $5,000
MAILING ADDRESS
CITY, STATE, ZIP
PROPOSED USE
� C
EXISTING ASSESSED /APPRAISED VALUE $_ 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)
L I co Ik
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXr rWr
PROPOSED
TOTAL
TOTAL EXISTING SF
TOTAL, PROPOSED SP
TOTAL SF
"NEW HOMES ONLY ** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type offixture 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 (o, Tub /Sbo CO A, )
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Bathroom Sinksl
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (Coninivmial)
RANGES
GAS WATER HEATERS
WATER CLOSETS (Touet) _
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 clairn (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
RELATIONSHIP TO
❑ Owner' CI Agent ❑ Contractor
DATE
('IStle)
❑ Architect ❑ Other
Bulletin #100.— .1anualy 7, 2005 Page 2 of 4 k \Handouts \Permit Application