06-101824 E i
RECE,A ED
Federal Way APR pERMIT
COMMUNlIYDEVELOPMENT SERVICES 1 2 2O0 SF MF CO ME EL PL DE EN P
33325 8n,AVENUE SOUTH•PO BOX 9718
FEDERAL WAY,WA 98063-9718 FE
.l.O
....._..„./253-8352607•FAX253835-2609 CRYOF IN ` 3,1CATION ii-----______,luww.cituoilederalwauxorrl ,. BU.tOINa DEP,,, I
The ollowin. is re• I
uired i ormation-an incom,iete a•,lication will not be acce•ted, Please ,rint le,ib[ (in ink)or p e.
PROPERTY INFORMATION
SITE ADDRESS I Zo-1 5, 3-.t� T I SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# -
LOT SIZE(sn
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate pogefor lengthy legal description)
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING KFIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
Loc...ie12- St. existrin1 5pa.i). ci_ L.S
PROJECT NAME(Name of Business or Owner Last Name) SA4e.A.IA Y
• PEOPLE INFORMATION
PROPERTY 1 NAME
OWNER �� ,� IA PRIMARY PHONE
MAILING ADDRESSIA -Item— (425-) 46?--3 4 L9
( CITY,STATE,ZIP
023 12 A-IT6 Ave- A W ELc•e1lul` W A • I.?coos—
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
MAD.INGADDREss✓1Srt'i4x...-�'tu,n "'(< Viily�4.D (1S3 )&i7Z -72aZ
CITY,STATE,ZIP CELL PHONE
76,T 5, %c>c i!' g•r,tt -r le-1,/,-i_ V,i.4 980 3 Z (z.4c. )G-79 -39‘/,S—
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
FAX NUMBER
B L / / ( )
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application)
EXPIRATION DATE
/ /
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
5hmt' ( ) -
MAILING ADDRESS CITY.STATE.ZIP
CELL PHONE
RELATIONSHIP TO PROJECT ( )
0 Architect 0 Tenant ❑Agent 0 Other(Describe) FAX NUMBER
( )
CONTACT I NAME PRIMARY PHONE I E-MAIL ADDRESS
SAWN ( ) - I
LENDERg NAME
MAILING ADDRESS CITY,STATE.ZIPPHONE
I ( ) _
111 DETAILED BUILDING INFORMATION
EXISTING USE`---ReT,ai t_ PROPOSED USE '3,4w 6-
,
, EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ A,90‘.:$
SPRINKLERED BUILDING? 0-YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? -YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
•
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
BASEMENT S9.FT. Sq.FT. SQ.FT.
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS I S`R'O PROPOSED I ,u, kT x'
Q•in
`*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(commrrcloI) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or'Mb/Shower Combo) SHOWERS WATER CLOSETS crone) 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./G r
NAME/TITLE �e i"4'(7 Si DATE 4-/ if
(Signatu Z- b
(Title)
RELATIONSHIP TO PROJECT 0 Owner ❑Agent ®-Contractor 0 Architect o Other
t z:tea a a
•
sant r• i .4f,or TT
:47C a � T7s� 3
w*.„.1,••'-‘,::,
ra
�E
Bulletin#100-January 1,2006 Page 2 of 4 k\Handouts\Permit Application