05-101378RECEIVED
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Federal Way AeAA IV8303� 11 $ 5 2005
COMMUNITY DEVELOPMENT SERVICES E R�� SF F CO E PL E EN FP
33325 STH ENUY,WA!•PO9718 (JOo� ,PLIC 1 *`/// �j�PWAY
FEDERAL 07- WA -98063 -260 ATn T yI`
253-835.2601• FAX 253 -8.com 9 � ��1
` www.dluoll"ederatuwu.com
The following is require"Wln bra aq¢n incomplete application will not be accepted. Please print legibly (in ink/ or tune_
SITE ADDRESS zD - ,Sou p -200 S7 l SUITE /UNIT #
ASSESSOR'S TAX /PARCEL # % f.� �� - V C�J LOT �
/SIZE (s / z j
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1) �r c r_ Z! , SCCOP -14 Soigur &4^)
(Attach separate page for lengthy egat de, awft.)
TYPE OF PERMIT X BUILDING ./PLUMBING MECHANICAL
❑ DEMOLITION EN I BERIIN, Gam❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work incl a on this rmitonitj
� l),
lt�1S C; f-01 LI /bloOScl L /C.-T/1 s-:W GO0Ve^
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
NAME � PRIMARY PHONE
MAILING ADD CITY, STATE, ZIP
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COMPANY NAME
APPLICANT
OFFICE PHONE
(ZOG ) z yZ -6.1y/
MAILING ADDR S
72 U� lv�`i Sr
CITY, ATE, ZIP
Fee , 4
CELL PHONE
(Z66)31??- - My
/-
G"���
(Zd(7P) ZYZ
7
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MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
( Wo 39Z
- 99wc/
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
-
— — — — — — — — — — B L
CONTRACTORS REGISTRATION NUMBER (copy of card regaired with each applicatioaj
EXPIRATION DATE
COMPANY NAME
AP LICA NAME �.�
AP
� G� N/
OFFICE PHONE
(ZOG ) z yZ -6.1y/
MAILING ADDR S
72 U� lv�`i Sr
CITY, ATE, ZIP
Fee , 4
CELL PHONE
(Z66)31??- - My
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe) OLVIV 4
NAME PRIMARY PHONE I EMAIL ADDRESS
qa Le ei formation ism, '
NAME
N
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o' tra ue a cc eds f 5 000, .
W 454 lb
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MAILING ADDRESS•
CITY, STATE, ZIP
2Uri'eAj
EXISTING USE / vS PROPOSED USE '62--
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $ LJ4✓V
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIIZED? ❑ 1. ❑ NO
WATER SERVICE PROVIDER 0LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER dLAKEHAVEN ❑ HIGHLINE dPWATE (SEPTIC)
s
f
1}
i
Indicate number of each type of fixture to be installed or relocated as part of this project. ' " coi include existing fixtures to remain.
ME CIi IMCAL
Value of Mechanical Work $ ��
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS
BBQS FANS HOODS (commercial)
BOILERS FIREPLACE INSERTS RANGES
COMPRESSORS FURNACES ° GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
BATHTUBS (or Tub/Sho— Combo) 4 SHOWERS
DISHWASHERS l SINKS
GAS PIPE OUTLETS SUMPS
WASHING MACHINES URINALS
. .11— - VACUUM BREAKERS
WATER CLOSETS (.iiei
DRINKING FOUNTAINS
RAINWATER SYST
- T- HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
{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 p o the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way as to any claim (incl in costs, expenses, and attorneys' fees incurred in the investigation and defense of
such claim), which may be made by any person, includ' dersigned, and filed against the City of Federal Way, but only where such claim
arises out of the reliance of the ci o s nd ernp ees, upon the accuracy of the information supplied to the city as a part of
this application. ,r
NAME /TITLE,,-
RELATIONSHIP TO
(Signatu
/ DATE
(Titko
❑ Agent ❑ Contractor ❑ Architect ❑ Other_
-29-6,5-
OFFICE USE
o NEW o ADDITION
o ALTERATION
o REPAIR o :TENANT IMPROVEMENT
BUILDING SHELL ONLY?
o YES a NO
BASIC PLAN? o YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE? ❑ YES
ONO
NEW ADDRESS REQUIRED? o YES o NO
UP /SEPA /SU ?. ❑YES
ONO
PLATTED LOT? o YES o NO
DEMO PERMIT REQUIRED? o YES
o NO
F
Bulletin 9100 —March 30, 2004 Page 2 of 4 k \l{andouts — Revised\Permit Application
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