05-104365an of /�•..: V
FederalWa ?ECE� PERMIT
co'w UM7TDEVELOFifENTSERWfSS 2005
333256M AVENUE s0(/7f /• FO BOX P LI C AT I O N
RBDERAL WAY, WA 9 8 087-9 718 ' - A D
253 - 8352607• FAX 253 - 635.2609 ,i4
Y OF FEDERAL
Qt m niNG DEPT.
SF MF CO ME EL PL DE E FP
D / /
SITE ADDRESS
aUi7'r; /ULM1T f
ASSESSOR'S TAX /PARCEL _ _ _ _ _ _ - _ _ LOT SIZE (s,)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separataPVge f-knOw kgd d— OftcN
• • JE;T INFORTIATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJEC C ION (Pro tailed description of work included on this permit onlul .
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE •• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME
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I/ � D 417 {± 14c cI MsT,,z,'P,, G /'D 005-
CO ANY NAME
Aj All
APPLICANT NAME
-
OFFICE PHONE _
10E_1
NO ADDRM
CITY, ATE f
,.PHONE
CITY OF FEDERAL WAY B/USI/N�ESS %L�ICB(N�SE ( Fg EXPIRATIONDATE
FAX NUMB ER
-
B L
( _
CONTRACTORS REGISTRATION NUMBER (copy of card required with each application) EXPIRATION DATE
COMPANY NAME
APPUCANT NAME
OFFICE PHONE _
MAILINO ADDRESS
CRT, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
( _
NAME U(r - - pRI OW •_ S� E-MAIL ADDRESS
r t{. ?p,...... �`f .f ,f,{,'i•t •.I!Y�;��X �_t;,�'�:1Xtit�'
EXISTING ASSESSED /APPRAISED VALUE
SPRINKLERED BUILDING? ❑ YES ❑ NO
WATER SERVICE PROVIDER L( L VEN
SEWER SERVICE PROVIDER & LAKEHAVEN
J`yM1 / 4+ ED US
VALUE OF PROPOSED WORK $ e2y
FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
• HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
• HIGHLINE ❑ PRIVATE (SEPTIC)
AREA DESCRIPTION ( E IS I G I P S FT. D I OFT.
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK (COVERED ?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS sx�ao
*NEWHOMES ONLY** NUMBER OF BEDROOM
Indicate number of each type of fixture to
NECHAMCAL
Value of Mechanical Work $
MAL
or related as part of this project. Wd not include existing fixtures to
NDLING UNITS
EV ORATIVE COOLERS
GAS LOGS
REFRIG. SYSTEMS
ANS
HOODS (cummomi,y
WOODSTOVES
RS
FIREPLACE INSERTS
RANGES
MISC (Describe)
RESSORS
FURNACES
QAS WATER HEATERS
S
GAS PIPE OUTLETS
A
UBS (or74 ho rCombo)
SHOWERS
WATER CLOSETS (ro&4
MISC (Describe)
ASH
SINKS
DRINKING FOUNTAINS
IP UTLETS
SUMPS
RAINWATER SYST
NG MACHINES
URINALS
HOSE BIBBS
9athmom
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I certVy 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 clataq, which may a made by any perso Including the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the relian of the city, Inclle is officers and employees, upon the accuracy of the information supplied to the city as apart of
this application.
NAME /TITLE DATE d �f /.Cl ✓�
(Signature) (rite)
RELATIONSHIP TO PR JECT ❑ wner ❑ Agent Contractor ❑ Architect o Other
Bulletin # 100 — January-?, 2005
Page 2 of 4
k\Handouts\Pcrmit Application