05-104270 ••
re'
RECEIVED
cm of
Federal Way PERMIT
AUG 2 3 2005 SF MF CO ME EL PL DE E P
COMMUNITY DEVELOPMENT SERVICES
33325 8TH AVENUE SOUTH•PO BOX 9718
FEDERAL WAY,WA 98063-9718 A P P L I C A' IO O E RAL..W•Y
0 253-835-2607•FAX 253-835-2609 ..
unuw.citiloffederalwa4.cam DUILDING DEPS. allillil
The ollowin• is re•uired in ormation-an Inco •Iete a.•lication will not be acce•ted. Please •rint le.ib/ in ink or j, -.
• PROPERTY INFORMATION
st
SITE ADDRESS _71t �1� ( • ,_ — Op UNIT#
ASSESSOR'S TAX/PARCEL# , 5_ 0_ _.J_ - O_L _ LOT_ SIZE(sf)
LEGAL DESCRIPTION (e.g.Acme estates,Lot 1)__ -
(Attach separate page for lengthy legal description)
IIIA PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL "❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on thispermit only)
oOck fr \core \' -P
l \I �- Cc x
PROJECT NAME(Name of Business or Owner Last Name) ( .)\C C_ x
IN PEOPLE INFORMATION
PROPERTY NAME ��/��/'���� 1 PRIMARY PHONE
OWNER M+i L AD,TJRES\ `i CITY,STATE, P �
•
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
talk - Y�.%e_c. r\,i�C,• i' 1Y1 (-ilk, CE Gt rt...-3,-)ti 9)3
MAIL NG ADDRESS (!`'��\. ` STATE,
ZIP
�/X��1-`�J,�J1(gA}` t/�]`,' CELL PHONE
�T'1)_ 10Y IIQESS NSF UMBER N`L Exk'IRATION DATE (AX NUMBER
g-g L-1 t2 ` t�-B L I� '�� 3q0• lSz�_5b
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATIONDATE
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
0, ( \'.. tic -b•i • _ J __.I� i > > i: w
AILING ADDRESS ,STATE,ZI• CELL PHONE
-1 C) 1 A-Ve . E : -Tat 0v4)-} ( ) 'N._7".
RELATIONSHIP TO O.IECT FAX NUMBER
❑ Architect 0 Tenant Agent 0 Other(Describe) a5^ 6�' -l_l1.,
CONTACT N MEC C�� PRIMARY PHONE�= i� E-MAIL ADDRESS
3 �1
LENDER Per ROW 19.27.095: Lender nformation is `", NAME
, required if project value sxceeds45,000
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE est= -W t t,F F\ck- I7LPC, PROPOSED USE eicriLJ
EXISTING ASSESSED/APPRAISED VALUE $ 1J( VALUE OF PROPOSED WORK $ A(,Ot,O s''
• SPRINKLERED BUILDING? 04...YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? DitYES 0 NO
WATER SERVICE PROVIDER Q1.LAKEHAVEN 0 HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ttit LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
• •
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
410 BASEMENT
113'kO &F
FIRST
SECOND Nt
THIRD
alPt-
FOURTH
ADDITIONAL FLOORS (DESCRIBE) I
ill
DECK(COVERED?) 14 ill
GARAGE 0 CARPORT 0 m
EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF '.TOTAL SF
NUMBER OF FLOORS 2 ‘13,0
**NEW HOMES ONLY** NUMBER OF BEDROOMS 14 1 ESTIMATED SELLING PRICE $ tJ
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(commeroia1) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUT TS
PLUMBING
• BATHTUBS or Tah/Showor Combo) SHOWER WATER CLOSETS rroiloq MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAYS(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 flied 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.
NAME/TITLE PetwL-r DE=3iGnJt;-2- DATE t-2.7'0.1.--
t
--Z?'-v�( ' ature) (Title)
RELATIONSH TO PROJECT ❑ Owner ❑ Agent kontractor ❑Architect 0 Other
"FOR OFFICE=USE°ONLY
❑NEW ❑':ADDITION ❑:ALTERATION o REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES o NO BASIC:PLAN?= e YES , .o NO
ZONING DESIGNATION - CHANGE OF»USE?r 'b YES - 0 NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES - o NO
PLATTED LOT? o YES ❑NO DEMO PERMIT REQUIRED? o YES a NO
•
Bulletin#100—August 19,2004 Page 2 of 4 k\Handouts\Permit Application