05-100508P ' RECEI *D
CITY OF F�a 0 4 2005
Federal Way PERMIT
COMMUNITY DEVELOPMENT SE� OF FEDER
33325 8T" AVENUE SOUTH • PO BO 7,.'►P L I C AT I O N
FEDERAL WAY, WA 98063 -97]8 UILDING D
253 - 835 -2607• FAX 253 - 835 -2609
www. cituoffederalwau. com
0
f �5-- 1 IV 56,55-
SF MF CO ME EL PL DE EN FP
be accented. Please
SITE ADDRESS 20 � S &r la � S SUITE /UNIT #
ASSESSOR'S TAX /PARCEL # _ - LOT SIZE (sfl
LEGAL DESCRIPTION (e.g. Acme Estates, Lot I) /�Gi ��L f I dYl� X/A - /' Z'
IAttach separate page for lengthy legal description)
or
PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICALLt
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT NAME (Name of Business or Owner Last Name)
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
GtS'J 2 e e/ Q04 ) 55 -& - 5110-130
IN ADDRESS CITY. STATE, ZIP
1 OX y ea
COMPANY NAME
_
APPLICANT NAME
OFFICE PHONE
0107 -) as
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXP ION DATE
2 CJ - Q 3 -L o y Z f Z 6- B L / /
FAX NUMBER
(yols -) 558 13 S
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
CO ANY !'NAME
lei ` `o r
APPLICANT NAME
OFFICE PHONE
(t/ ) 07 -0?// 6
MAILING ADDRESS L(�
5/%00 /weer,/
CITY, STATE, ZIP
CELL PHONE
( ) -
RELATIONSHIP TO PROJECT l l
❑ Architect ❑Tenant ❑Agent Other (Describe) �U C 10 T
FAX NUMBER
(1/01, - R�
NAME PRIMARY PHONE EIMAIL ADDRESS
Per JWW 19.2? 1!515; Under ',infarmat {on fs
required tf prafect 6glue ezceed4 0.000
NAME
MAILING ADDRESS
CITY, STATE, ZIP
PROPOSED USE
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $ Y • W
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)
AREA DESCRIPTION
EXISTING
S!2. FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FIRST
EVAPORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
SECOND
FANS
HOODS (comm«oiaq
WOODSTOVES
THIRD
FIREPLACE INSERTS
RANGES
MISC (Describe)
FOURTH
FURNACES
GAS WATER HEATERS
ADDITIONAL FLOORS (DESCRIBE)
GAS PIPE OUTLETS
DECK(COVERED ?)
GARAGE ❑ CARPORT ❑
SHOWERS
WATER CLOSETS praiieq
MISC (Describe)
NUMBER OF FLOORS
®asrmo
PROPOSao
TOTAL
TOTAL YX 000 eP
TOTAL PROPOSED sr
TOTAL"
* *NEWHOMES 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.
MECFIAMCAL
Value of Mechanical Work $
AIR HANDLING UNITS
EVAPORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
BBQS
FANS
HOODS (comm«oiaq
WOODSTOVES
BOILERS
FIREPLACE INSERTS
RANGES
MISC (Describe)
COMPRESSORS
FURNACES
GAS WATER HEATERS
DUCTS
GAS PIPE OUTLETS
PLUMBING
BATHTUBS (- Tnb /sho -C—bo(
SHOWERS
WATER CLOSETS praiieq
MISC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPE OUTLETS
SUMPS
RAINWATER SYST
WASHING MACHINES
URINALS
HOSE BIBBS
LAVS (Bathroom sinks )
VACUUM BREAKERS
ELECTRIC WATER HEATERS
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 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. / 7
NAME /TITLE DATE
gnat e( (Title)
RELATIONSHIP I PR ECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 — January 7, 2005 Page 2 of 4 k\Handouts\Permit Application