06-106115cny.,A RECEIVO b
Federal Way - -���
COMMUNITY DEVELOPMENT SERVICES
EC 0 12006 PERMIT SF MF CO ME EL PL DE E]
33325 8m AVENUE SOUTH • PO BOX 9718
FEDERAL WAY, FAX 98063-9718 -26 ® :111or.AWLI CATI O N
253 - 835 -2607• FAX 253 - 835 -26
www.dt�yoffederaiwcw_com 1,9� 4 501.
The -followinq is re uired information -an incom fete alMlication will not be accei2ted. Please rant le ibl ink or
4 / PROPERTY •. •
SITE ADDRESS B ( >. 3�� �Sr F 7' SUITE /UNIT # 40/03;
ASSESSOR'S TAX /PARCEL # _ - _ — LOT SIZE (Sfi
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate page for length/ legal descrtptloN
PROJECT • •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING KFIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this hermit onlu)
/,,(lsi�ru�j< Or= AV017-7-w 7T) gr rsr -04 ><• ilt •� ,d7
PROJECT NAME (Name of Business or Oumer Last Name) &ud,+ T�
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
PEOPLE INFORMATION
NAME
PU s u1 L[ c
PRIMARY PHONE
( 2,5- �s3 - iaod
MAILING ADDRESS
/S /,f -*, S 5re j00
CnY, STATE. ZII'
COMPANY NAME
/
A�P�PLLIICANT NAMEy
OFFICE PHONE
7 M
MAILING ADDRESS
8z8 OPLA(Z-
PLC -
Cr STATE, ZIP
- lqf
CELL PHONE
(I ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
o- o Z- 1
0_ S 11 q 7- / /
V6 7Z-(-, -9140 0
B L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each application)
EXPIRATION DATE
l v 136 10-7
E A-C s F
E S 1 ? 3 P Lk
CO ANY NAME /
6A -et ,GC C >e' t? J;x4u
APPLICANT NAME
°7,,4 "'7-J
OFFICE PHONE
(206)M' - 3 80(o
MAILING ADDRESS
a PO AU A-✓c OtAC.C- Sc,.Y -
CITY, STATE, ZIP
L-'�
CELL PHONE
( ) -
RELATIONSHIP TO PROJECT
❑ Architect El Tenant ❑Agent ❑Other (Describe) C��'R�7t�L
FAX NUMBER
(2Cb )7Zf:, - e 160
NAME PRIMARY PHONE E- ADDRESS
°T1, �stmAd (�� ) 7&k - 3�o z " e ePP-S, a z
NAME
MAILING ADDRESS CITY, STATE, ZIP PHONE
EXISTING USE PROPOSED USE
o�
EXISTING ASSESSED /APPRAISED VALUE $ VALUE OF PROPOSED WORK $ /*7600•
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHIdNE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 11 HIGHLINE ❑ PRIVATE (SEPTIC)
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ. FT. I SQ. FT. I SQ. FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK (COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS ZUWnNo raoros®
"NEW HOMES ONLY" NUMBER OF BEDROOMS
TOUL
ESTIMATED SELLING PRICE
number of each type of fixture to be installed or relocated as part of this project. Do not include existing f fixtures to remain.
MECFIANICAL
WATER CLOSETS (roueU MISC (Describe)
Value of Mechanical Work $
DRINKING FOUNTAINS
AIR HANDLING UNITS
EVAPORATIVE COOLERS
BBQS
FANS
BOILERS
FIREPLACE INSERTS
COMPRESSORS
FURNACES
DUCTS
GAS PIPE OUTLETS
BATHTUBS (or Tub /shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (Bathroom sinks)
GAS LOGS
HOODS (c.rcw)
RANGES
GAS WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
SHOWERS
WATER CLOSETS (roueU MISC (Describe)
SINKS
DRINKING FOUNTAINS
SUMPS
RAINWATER SYST
URINALS
HOSE BIBBS
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I certt under penalty of perjury that t 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 ve emises to perform the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way o a claim (including costs, expenses, and attorneys' fees incurred in the investigation and defense of
such claim), which be . ade y n, including the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the lance o t ng i cars and employees, upon the accuracy of the irtfor oration supplied to the city as a part of
this applicatio .
I/ 2 —0/—C) ft)
V (Signatarisl C � (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 - January 1, 2006
Page 2 of 4
MandoutAPennit Application