05-100073r e ...
f CEIVED
JAN 0 7 2005
Federal Way
pp IT FP
CITY OF FAD SF MF CO ME EL PL DE EN
COMMUNITY DEVELOPMENT SERVICES
!?`RAt 4��
33325 AVENUE SWATH•PO BOX 9718 A t9 r�A T I O N TD
FED ERAL WAY,WA 98063-97]8 / /
253-835-2607•FAX 253-835-2609
www.citya ffederalwau.cont
The ollowin• is re•uired in ormation-an incom•lete a••lication will not be acce•ted. Please •rint le•ibl in ink or f•e.
• PROPERTY INFORMATION
SITE ADDRESS& Z
dW - . f G1sf,8 .BOO/ S j'c /JI Y C SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# /iih`— �l --�,/ ?LOT SIZE(si
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1 T/ 3 17,/,, • ��(j'1'1 7 1• - - fz
(Attach separate page far gfhy legal descnphoc)
• PROJECT INFORMATION ,y1
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL'Si/•,C /�/�/n
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROD T D C PF10 '(Provide detailed description of work include on this ermit only)
G� 7 V -h/'t
a/at,n in of
-f6/' gCtlaCkani T
PROJECT NAME(Name of Business or Owner Last Name)liQOO63077 7. d/c aS N/c/"• V f
II PEOPLE INFORMATION
PROPERTY NAA E`` / l PRIMARY Pu/n`NF
OWNER /(',c AleehaTelo/0/0� ! /' 676fO) JS8-go3Q
ING ADDRESS / / ! / CCl C ez/ I'AP
/ 64 99/aY
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
7;e2.-/(411/e . � e. (t/0 1 5 '/62
MAILING ADDRESS - C STATE,ZIP CELL PHONE
OW S/3 /s0)" /lam( ti� OftaWA 9Po50) ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
a o -6 3 -L o 3 v 6-B 1-, / / (Va5)ss8 - V/3,
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
APPLICANT COMPANY ANAME //n y� APPLICANT NAME OFFICE PHONE /
/P/ e C/J i O, ,9/bE .SY C STATE,ZIP (yt75)N 9'r2 - 2//!�
MAILING ADDR S
c%o , %3'-QM 044 Air al )/ 12&V�6)) 9 36 ( ) -
RELATIONSHIP TO PROJECT i/' 1 FAX NUMBER %�
❑ Architect ❑ Tenant ❑Agent XOther(Describe)3c(,t6-LOA-tr'aetor ((/di) '97-O�/s$-
CONTACT NAME4e/i ek/4 was)H 97- 07/16 /OK a,rtsyglP rvesi{
LENDER Per RC W 19,27,095: Lender information is NAME
required if project ect value exceeds$5 0011
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 598.V Od
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)
•
. � . S
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
—
DECK(COVERED?)
-
GARAGE ❑ CARPORT❑
ExisnNO PROPOSED TOTAL 'TOTAL 8X[SM(6 8P TOTAL PROPOSED BF TOTAL SF"
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS _ FANS HOODS(commercial) WOODSTOVES
BOILERS _ FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or Tub/shower combo) SHOWERS WATER CLOSETS(Toilet) 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
DISCLAIMER/SIGNATURE BLOCK
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. //V
A'SDATE // V S
ature) (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
41OICE USE ON
NEW ❑ADDITION ❑ALTERATION ❑REPAIR a'TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? a YES a NO
ZONING DESIGNATION CHANGE OF USE? a YES a NO
NEW ADDRESS REQUIRED? o YES ❑NO UP/SEPA/SIT? ❑YES a NO
PLATTED LOT? ❑YES a NO DEMO PERMIT REQUIRED? a YES q NO
Bulletin#100—August 19,2004 Page 2 of 4 k\Handouts\Permit Application