05-100276 1.
cm.of _ — 1) 7 62,
Federal Way PERMIT
COMMUNITY DEVELOPMENT SERVICES SF MF CO ME' ,«�! PL DE EN FP
33325 8T"AVENUE SOUTH•PO BOX 9718 APPLICATION .JTD
FEDERAL WAY,WA 98063-97]8 / /
253-835-2607•FAX 253-835-2609
u+m u+.at yo/jede ralu+a q.com
The following is required information-an incomplete ap.lication will not be accepted. Please print legibly(in ink)or type.
,'s'- - �y• ,{ • - N,PROPERTY INFORMATION
SITE ADDRESS f G 22 ‘ r "lf Sl Il ' ael-61SUITE/UNIT#
1 43
ASSESSOR'S TAX/PARCEL# LOT SIZE(s)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal descnpnon)
1
X 4%.,-,'t . >f._ ,' MI.PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING�1 . 'IRE PREVENTION SYSTEM
PROJECT DESCRIPTI (Provide detailed description of work included on this permit only) 1t
LA stall Ye ) Vs( 1 s ,St1/1
PROJECT NAME(Name of Business or Owner Last Name) 1*—t, S It ( 6Q.6 Z` I
I1 PEOPLE INFORMATION
PROPERTY NAM t fj, �- r PRIMARY PHONE
OWNER J\)(j5OV\ I1(� jth nevi 1 Ti11 ( ) -
MAI2333 DDRES$., Y 'I�on ��t CNv f,la�ld '1`i 3 3
CONTRACTOR COMPANY NAME 1/\Y'1` AP LICANT AME OFFICE PHONE
J j yT dive ,( C�1v1 � a Off*4,1 (2Dc9 ) 72.3 -q3/�MAILINF S t CITY ATE, I CELL PHONE
'4 01 61'0 ( ) _
CITY OF FEDERAL WAY BUSINESS LICENS NUMBER EXPIRATION DATE FAX NUMBER
/ / ( )
B L
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
APPLICANT COMEY IIAME APP ICANT AME OFFICE PHONE
O .IV�'A tri rD CC41Ov� Mty.'I C( c (2( ) 72_3 -1)6/2-
MAILING ADDRESS ` CITY,S TE, P CELL PHONE
RELATION1S IP PROJECT S i- c l 1� 40 ci '18 (AX NUM)ER
❑ Architect ❑ Tenant ❑Agent ❑ Other(Describe) ( ) -
CONTACT NAMEP MARY PHONE E-MAIL ADDRESS
(CIA,c ae\, .6
LENDER Per RCW"19.27.095: Leder information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP
■ DETAILED BUII.DING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 1 2 b 0
SPRINKLERED BUILDING? 0 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQ _: . . • in t•
WATER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE a TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE a PRIVATE(SEPTIC)
•
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING SQ.FT. P• .SED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DE • BE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS? OTAL EXISTING TOTAL PROPOSED TOTAL EXISTING ASD PROPOSED
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES =.
Indicate number of each type offixtur- o be installed or relocated • .art of this project. Do not include existing fixtures to remain.
' MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNI'• EVAPORATIVE COOLERS GA- OGS REFRIG.SYSTEMS
BBQS FANS HOOD comm«riat) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRES=QRS FURNACES GAS WATER ' ATERS
DU GAS PIPE OUTLETS
PLUMBIN
BATHTUBS or Tub/ShoaerCombo) SHOWERS WATER CLOSETS(roue) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sulks) VACUUM BREAKERS ELECTRIC WATER HEATERS
'DISCLAISIER)SIGNATURE BLOCK
I certify under penalty of perjury that the i f. ation 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 pre ises 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.
a
1/2.!
1NAME/TITLE Q.,tikes,
DATE {I2.!
I (Signature) (Title( !
i RELATIONSHIP TO PIWECT ❑ Owner o Agent Contractor ❑ Architect ❑ Other
.
I FOR OFFICE USE ONLY
a NEW Y a ADDITION a ALTERATION o REPAIR d TENANT IMPROVEMENT
� BUILDING SHELL ONLY? ❑YES o NO BASIC PLAN? o YES o NO
1 ZONING DESIGNATION CHANGE OF USE o YES o NO
t NEW ADDRESS REQUIRED? a YES a NO UP/SEPA/SU?. a YES ❑NO
PLATTED LOT? a YES o NO DEMO PERMIT REQUIRED? a YES a NO
Bulletin#100—March 30,2004 — Page 2 of 4 k\Handouts—Revised\Pcrmit Application