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Federal Way ,JUN 2 4 2005 PERMIT
COMMUNITY DEVELOPMENT SERVICES
333TSQTHAVE/VUESWA 9 FEDERAL ,PLI CATI O N
FEDERAL WAY, WA 98 7 I LDING DEPT
?53- 835 2607• FAX 253 d35 -2
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will not be accepted. Please
SITE ADDRESS 1()15 S 3JIE5 �
ASSESSOR'S TAX /PARCEL # - -a a 1 10
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
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TYPE OF PERMIT
- ■ PROJECT INFORMATION
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
SUITE /UNIT i
LOT SIZE (sf)
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING +IRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this Permit onlul
l S— � �!?.., Ia n ►'2 JAifE,_
PROJECT NAME (Name of Business or Owner Last Name) _A(7�J1'� Joke,
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
NAME PRIMARY PHONE
MAILINO ADDRESS CITY, STATE, ZIP
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COMPANY NAME
� � R _
APPLICANT NAME
OFFICE PHONE
(25>)!542q- - Lf& .
MAILING ADDRESS
CITY FEDERAL WAY BUSIN LICEN3 NUMBER
CITY, STATE, ZIP Lt
EXPIRATION DATE -
CELL PHONE
FAX NUMBER
— — — — -B
L
i' +�
CONTRACTOR'S REGISTRATION NUMB copy of card required with each appUcattoul
EXPIRATION DATE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant Agent ❑ Other(DescribeJ
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAILING A RESS
'�
CITY, STATE, ZIP —
'�
CELL PHONE
i' +�
�•
( ) 2^14 - 3Z
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant Agent ❑ Other(DescribeJ
NAME
EXISTING USE C {" rt Ce PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ cV VALUE OF PROPOSED WORK $_a op t>
SPRINKLERED BUILDING? ONO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? O'Q ❑ NO
WATER SERVICE PROVIDER HAVEN ❑ HIGHLINE c3 TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER LAKEHAVEN O HIGHLINE ❑ PRIVATE (SEPTIC)
J
ZMMA urac:acarraun EXISTING PROPOSED TOTAL
SQ. FT. I SQ. FT. SO. FT.
SECOND
THIRD
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED7)
GARAGE O CARPORT ❑
NUMBER OF FLOORS sXISao r
'NEW HOMES ONLY" NUMBER OF BEDROOMS
Indicate number of each type of fixture to be
ALWWANICAL
Value of Mechanical Work $
or rested as paKof this project. Do not include existing fixtures to
AIR HANDLING UNITS APOPATIVE COOLERS GAS LOGS REFRIG. SYSTEMS
BBQS FAN3 HOODS pommerciq WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES
MIS (Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUAMNG
BAT S (or7Vb /Show rCombo) SHOWERS WATER CLOSETS Iroikq MISC
HWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES U NALS HOSE BIBBS
LAVS (e.rhroom sw* VICUUM BREAKERS ELECTRIC WATER HEATERS
I cert(N under penalty of perjury that the( n*rmation 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 clainq, which may be made by any person, including the undersigned, and filed sled 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 DATE Le
(Signature (1YUe(
RELATIONSHIP TO PROJECT ❑ Owner CFAgent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 —January 7, 2005 Page 2 of 4 MHandoutMennit Application