06-105387 )a 1(4al0.
Federal Way RECEIVES PERMIT — j 3 e
COMMU AVENUTTY VELOPMEKfSERVICES SF MF CO ME EL PL DE EN FP�
33325 8TM AVE u5 S01/77f•PO EOX 97]8 n
FEDERAL 7Y,FAX
93-8 3-260 ''�' l' 2g�ep P L I C A T I O N TD
253-835-2607.FAX 253-835-2609 /
• www'c'tw'ffederalwaurnm'ITV OF FEDERAL WAY
The ollowi • is re•tAtil 1 • `•n an incom.tete a..lication will not be acce.ted. Please •Tint le.ibl in i or •e.
■ PRO ERTY INFORMATION
SITE ADDRESS 77 / A / € )tINIT# 4 )2j
ASSESSOR'S TAX/PARCEL# i 5 0 p_il‘-- 0
I _O_C) LOT SIZE(si)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal deur-Than(
_ • ■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 'FIRE PREVENTION SYSTEM
detailed DESCRIPTION(Provide description of work included on this permit only)
aiC1 ce‘A y
PROJECT NAME(Name of Business or Owner Last Name) 1-)/ L L / 1 Ill.5 77 17 -
- • PEOPLE'INFORMATION . -.
PROPERTY NAME
1/ 1 ) n J��Q./ PRIMARY PHONE
OWNER
IL
OWNER
S �r\r' ATE ( )
• NG
CI ,
CONTRACTOR COMPANY NAME APPLICANT NAME +
OFFICE PHONE
atlDEEEEL\Y(p ��^ -l `A/ 6/1 X a/)�vT)R
Pl /A\`J CELL PHONE
lFFED RAL�AY BUSINESS 1 NS NUMBER ~ P Io DTE �,
_ FAX NUMBER
CONTRACTOR'S1 oLc) (3 -1- ci - j,1,_
REGISTRATION NUMBER(copy of card required with each application)
4.-? p,--T- \7 _1 ? ii q ,� I EXPIRATION DATE
APPLICANT MPANYONAME ►N� �/ 77) /
L[CANT NAM \� OFFICE PHONE( _ J]�
1N GA \(e, ?) l t Jt�` / 11
L OADD E S 1L
'^xJ (}-71 CITY.ST ZIP - CELL P N
R N IPTO.RU ' - t- t '�I ( ia- .� , _
R❑Architect ❑ Tenant ❑Agent ❑ Other(Describe) FAX NUMBER -{ (}
L
CONTACT NAirt � (� �� �
I `(\ ` A , PRIMARY P ONE E-MAIL ADDRESS
LENDER vv �_ /, D
^� 'p� ! f :ze el drt. I, r -1 ,f tary%t') c' NAME Ci�.
f MAILING ADDRESS
CITY,STATE,ZIP
f
- ' . • • R DETAILED BUILDING INFORMATION '
iii
EXISTING USE Re-1a; iPROPOSED USE ITA )
A V{�rre
EXISTING ASSESSED/APPRAISED VALUE
VALUE OF PROPOSED WORK $ ({-800
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES ❑ NO
WATER SERVICE PROVIDER o LAKEHAVEN 0 HIGHLINE 0 TACOMA, a PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑PRIVATE(SEPTIC)
•
' PROJECT FLOOR AREAS sem` .
AREA DESCRIPTION EXISTING PROPOSED TOTAL
S•.FT. S.. FT. S..FT.
BASEMENT
FIRST _____: _q--{L8
0
SECOND
THIRD
FOURTH •
ADDITIONAL FLOORS(DESCRIBE)
•
DECK(COVERED?)
GARAGE ❑ CARPORT 0
MISTING PROPOSED TOTAL S Oe., L,of,:',,,,.1: OTA:P�R'OP0s,ED NF EP ' SAL Br
NUMBER OF FLOORS h ` 1 ,..454S?"' x a04= :;.-A,
,: ; .ry<.
**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(commereia) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES G• MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(orTub/shower Combo) SHOWERS WATER CLOSETS(roue) 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 III
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. J/, ��
NAME/TITLE //‘-.-- - �i(,� DATE /V --2-C---OK
(Title)
RELATIONSHIP TO PROJECT 0 Owner 0 Agent 0 Contractor ❑ Architect .e'Other 5Ci.6 C-91141,.:.:kr-
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Bulletin#100-January 7,2005 Page 2 of 4 k\Handouts\Permit Application