05-100555 cir f•,
- / a S
Feder!Way R 0 7 200
COMMUNITY DEVELOPMENT SERVICES
PERMIT �� ASF MF CO ME EL PL DE E FP
3353EDFIRST AWAY,WA9•PO BOX 3-9718 18 APPLICAI
FEDERAL WAY,WA 98063-9718 ��+�(AL WAY
/ /
253-661-4115•FAX 253-661-4129 I ND DEPT, Il I
www.tatilof etieralwau.corn
2'.,;;s' 24(' 7
The ollowin• is re•uired in ormation-an incom.fete a••lication will not be acce•ted. Please •rint le•ibl in in or
�j NI PROPERTY INFORMATION
SITE ADDRESS �J �[ ii g261711 p j SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# 'J t 2 , 9 - -7 —1 6 LOT SIZE (sf)
LEGAL DESCRIPTION (e.g.Acme Estates, Lot 1) G�i&-i-1/4-0c1 SE
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
w tKATI ri A.i► s►)�. Zlu . LUi E'l#�/vtuok, ).Pocc%sk. , � Chi
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PROJECT NAME(Name of Business or Owner Last Name) '1 W1 Lacs (c)L,f (04;4.
IN PEOPLE INFORMATION
PROPERTY NAME 1 PRIMARY PHONE�ff, 9440
j 71
OWNER 1�/`A V --itki � (4_1 .r' C � (� ) P.--1 - i f�l 0
MAILING ADDRESS %� C Y,STATE,Z-L L )
iii
CONTRACTOR COMPANY NAME APPLICANT NAM.?__ OFFICE PHONE
_ '`-1 ISE- C me P/ttc. - u c.;E- _ (412 ) (o(3( - 212:7
MAILIN AD ESS tocl TY,STATE,ZIP CELL PHONE
ervB
C TY OF FEDERAL WAY BUSINESS
�LICENSE NUMBER EXPIRATION DATE FAX NUMBER �,,/
1 1 -I C1 - 1 0 J ° 2 L- B L / / (LOS) 6Z l L
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATIO DATE
L e- E C fra -0asby l alb ld0
APPLICANT COMPANY NAME .7.,R ICANT Npt OFFICE PHONE
ilk CSF � J, ,.,�- )Z. (4(?S)641 - 2.-12:7
MAILING ADDRESS CITY STATE,ZIP CELL PHONE
.3. !-t (a Wi4 1603 (y2.$ ) Y((3 - 4'170
RELATIONSHIP TV PROJECT FAX NUMBER )
❑ Architect ❑ Tenant ❑Agent ijl Other(Describe) (C,.rNt `L-- (12Z) 51b f/-(i([J/_
Z.--
CONTACT NAMF�_,
PRIMARY PHONE
E-MAIL
tel t-, ( 425) N3- ti _ Tv�.�
LENDER Per 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP y
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ � �()..d
SPRINKLERED BUILDING? 0 YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
J
• ,Y P
�• PROJECT FLOOR AREAS `-'/
AREA DESCRIPTION EXISTING PROPOSED TOTAL
BASEMENT SQ. FT. SQ. FT. SQ. FT.
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
**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 futures to remain.
MECHAIVICAL
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
R.� 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 :aim(including costs, expenses, and attorneys'fees incurred in the investigation and defense of
such claim), which may be made by any persoincluding the undersigned, and filed against the City of Federal Way, but only where such claim
arises out of the ante of the city, includinits .fficers and employees, upon the accuracy of the information supplied to the city as a part of
this application. r
�._. c
NAME/TITLE 1 . L�j.I. 14.A' ;. DATE -1 OW Celt 20C)
( gnature) (Title)
RELATIONSHIP TO PRO CT 0 Owner 0 Agent Contractor 0 Architect 0 Other
FOR OFFICE USE ONLY
NEW ❑ADDITION ❑ALTERATION ❑REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES a NO BASIC PLAN? ❑YES a NO
ZONING DESIGNATION CHANGE OF USE? ❑YES ❑NO
NEW ADDRESS REQUIRED? ❑YES ❑ NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? ❑YES ❑ NO DEMO PERMIT REQUIRED? ❑YES a NO
Bulletin#100 March 30,2004 Page 2 of 4 k\Handouts—Revised\Permit Application