05-105337Federal Way
COIIMUNRYDEYELOPMBNf SERVI=
333258- AVENUE SCUM • PO BOX 9715
FEDERAL WAY, WA 98063.971E
753 - 835-2607• FAX 25343S -2609
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Thefollowina is reavdre
SITE ADDRESS
PERMIT
APPLICATION
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will
SF MF CO ME EL PL DE EI! FP
ASSESSOR'S TAX /PARCEL f a_ '21 a 0 Z- -I U a 0 —Qg
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
SUITE /UNIT #
LOT SIZE (sn
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PROJECT •• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING i•J FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this rmit onlEd
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PROJECT NAME (Name of Business or Owner Last Name) hl c Yary%ix Ck love Afy,'t� 71
PEOPLE •• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
s-Qo +Nj I (;i;i-51 -? a -0
MAILINU ADDRESS I I CITY, STATE, ZIP
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COMPANY NAME
vNi k 'reS rvLS
APPLICANT NAME
mic�lojeA ) I
OFFICE PHONE
(�3) 9a6 - /8
MARdNO ADDRESS
I . O & -7 Ave,
CITY, STATEE,, ZIP / . I) /y� may"
ax-a M4 W [ NA
CELL PHONE
( ) r
CITY OFFEDERAL WAY BUSINESS LICENSE NUMBER
L -$ 1 -D 4 Q -s.
EXPHiAT[ON DATE -:
4200E
'FAX NUMBER
U5-3)9,)-.6 5
L
CONTRACTORS REOISTRATION NUMBER (copy of card required with each appUattoa)
5 n^L -1 1 -4 E�i L 3 6'0T
EXPIRATION DATE
It
COMPANY NAMEI
C
APPLICANT NAME
OFFICE PHONE
MAID NO ADDRESS
CITY, STATE, ZIP
CELL PHONE
REIATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Desm -be)
FAX NUMBER
( ) -
NAME
PRIMARY PHONE
E- MAILADDRESS
NAME
MAILING ADDRESS .... CITY, STATE, ZIP
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $. 3 3 6 1. OO
SPRINKLERED BUILDING? a YES o NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? o YES a NO
WATER SERVICE PROVIDER O LAKENAVEN O E IGHLDPE O TACOMA o PRIVATE (WELL)
SEWER SERVICE PROVIDER o LAKEHAVEN 13 HIGHLINE 0 PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVEREDI)
GARAGE ❑ CARPORT ❑
iAefaO
NUMBER OF FLOORS ros reem TOTAL ..__...._ _ ._
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
each type
Value of Mechanical Work
_ AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS /
(er'Tub /Sho,ww combo(
9M PIPE OUTLETS
WASHING MACHINES
to be
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
OAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
as paq of this
to
GAS LOGk REFRIG. SYSTEMS
HOODS (cmA.,,< WOODSTOVES
RANGES MISC (Describe)
OAS WATER HEATERS- .
WATER CLOSETS (rwkq MISC (Describe)
DRINKING FOUNTAINS
RAINWATER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
I cer ft 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 each 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 appNcation.
NAME /TITL DATE 1&4 f05—
(Signature) ('Nne) 7
RELATJONSHIPf/O PROJECT ❑ Owner ❑ Agent ❑ Contractor O Architect XOther CO r 1 PJt-
Bulletin tI100 — Jaauary 7, 2005 Page 2 of 4 klHandoutslPamit Application