04-104916 sr ` ,/ V/J� /
J CITY OF O q /0 Y' / I /a
Federalway RECEIVED PERMIT f «`fff/// 1
COMMUNITY DEVELOPMENTSERVCES SF MF CO ME EL PL DE EN
33325 8TH AVENUE SOUTH•63 BOX 97]8 TD
FEDERAL WAY,WA 98063-97]8 DEC 0 6 APPLICATION
253-835-2607•FAX 253-835-2609 - ---- - ,.
www.attioffederalwaw.com �� /
The followin. is£41,11, (y, . ;tjlriA1-idyl incom.lete a.•lication will not be acce'ted. Please •rint legibl in ink or .e.
• PROPERTY INFORMATION
SITE ADDRESS 3,s r •i.A.; Olj- SiT . Ic.c I/� j GUR . SUITE/UNIT#
ASSESSOR'S TAX/AR L# Si 1) 3 1 f 0 a�Lt / LOT SIZE(s)
LEGAL DESCRIPTION (e.g.Acme';states,t 1) O
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DES RIPTION (Providedetaileddescription of work included on this permittonit)
N rr'c to Cca 1C r In-eol S •�,r YI e Gt/ Gti ct.l2. ., d- C t, 1 i n,p
PROJECT NAME(Name of Business or Owner Last Name) 774" L �.:) Co h-c I\(�.G� -h
'^ r1Gi1R:' i3.,
• PEOPLE INFORMATION
PROPERTY NAME /^ /+ (i // PRIMARY PHONE
OWNER 7;:<:;i A 1.---.c, L V-a d' 1 4,1 ta V-1 (C..UL ( ) -
MAILING ADDRESS V ( CITY,STATE,ZIP
33-&3 sw 3a� s� - r1,,,,01 ai 'A. `� k
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Pa�-1( OA- .iii Pro. c�;a.-• Tit . iNin �cAc.c cti. (as,5)`rale - 1l D r
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
g70> `70`x1;'‘ 4vt. C. Jaz-, CA.rot ‘1,511( ( 2s3) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER 7
-1 1- q I-J i 2 x v-B L 0 1 3( b`( (7-3) (Ia). -Lise
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
23TRiP- POtel_ C - /a i .; /O6
APPLICANTPANY NAME APPLICANT NAME OFFICE PHONE
l� ipf 1r� Peary '43v./MU_. :ak.\ IJa,tc-. (As ¶aG -.1.190MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
OT'70'? ' c E , /OLC CNA,N W►A Iktai ( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant 0 Agent 0 Other(Describe)F3 e,,44,e i'0✓- (o?s3) 5-a -44,321
CONTACT NAME ' PRIMARY PHONE E-MAIL ADDRESS
`It,,v\ -1 :C ,—. (,9:>3) `rai• - ' o
LENDER Per RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000' '
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 3S1 V-
SPRINKLERED BUILDING? 0 YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
•I f
•.,
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ. FT. SQ.FT. SQ. FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FLOORS EXISTING PROPOSED TOTAL TOTAL EXISTING BF 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 fixtures to remain.
MECHANICAL
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/ShowerCombo) SHOWERS WATER CLOSETS(Toilets 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. / /
NAME/TITLE Aigl:ature))9/141�" DATE /�/i [o``I(Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent X Contractor ❑ Architect ❑ Other
FOR OFFICE USE ONLY
o NEW D ADDITION 'ALTERATION o REPAIR ATENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES o NO
ZONING DESIGNATION CHANGE OF USE? ❑YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES ❑NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? a YES ❑NO
Bulletin#100—August 19,2004 Page 2 of 4 k\Handouts\Permit Application