06-100937 CITI�OF'���M
RECEIVED• 0
Fed: iWay PERMITn <� (p - L6 0 3 �
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FED �r 2006 Sr MF CO ME EL PL DE E (j)`
33325 81W AVENUE 5011771•PO BOX 9718
534 607 FAX 2DERAL WAY,WA 553-835-2609 A P P LI C A � , I.WAr �—
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The ollowin• is re•aired i ormation-an inco •fete • • •lication will not be acce,ted. Please ,rint legibly in i or
1111 PROPERTY INFORMATION ,
SITE ADDRESS (71 /2t) ' SP-0746 `
) 0/l SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# 3 L 0 - 0 a LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
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■ PROJECT INFORMATION
TYPE OF PERMIT ❑BUILDING PLUMBING 0 MECHANIC
0 DEMOLITION ELECTRICAL 0 ENGINEERING FIRE PREVENTION SYSTEM
PR T DESCRIPTION(Provide detaild description ;cork Inc ded on this permit onlu)
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PROJECT NAME(Name of Business or Owner Last Name) P /Wo /4/01,1
II PEOPLE INFORMATION
PROPERTY NAME �j PRIMARY PHONE
OWNER 1 a-iYr k Ck 1v(/. / o ccci, .( )
MA ADD&ESS CITY,STA Zi
CONTRACTOR COMPANY NAME
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� AP,P�CANT NAME OFFICEO( PHONE
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CITY OF FEDERAL WAY U�J "— CENSE NUMBER— EXPIRATION DATE FAX NUMBER _
IC B L . / / ( )
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
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APPLICANT COMPANY E APPLICANT NAME (OFFICE PHONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
RELATIONSHIP TO PROJECT �AX NUMBER
❑Architect ❑`Tenant a Agent a Other(Describe) ( ) _
CONTACT NAME - • PRIMARY PHONE E-MAIL ADDRESS
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. ( )
LENDER �`
'-.t,'< '�.�t.Cr-<Ea i. �_, :r,•3 - NAME
dMAILING AD' .:-.. CITY,STATE,ZIP
PHONE
■ DETAILED BUILDING INFORMATION'
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ /j Po?)
SPRINKLERED BUILDING? 0 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? a YES ❑ NO / s
WATER SERVICE PROVIDER a LAKEHAVEN a HIGHLINE a TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN a HIGHLINE a PRIVATE(SEPTIC)
• •
{ , 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 0 CARPORT 0
NUMBER OF FLOORS PROPOS= AL
**NEW HOMES ONLY NUMBER OF BEDROOMS ESTIMA D SELLING PRICE $
FIXTURES
Indurate number of each type of fixture to be installed or reloc• e' . part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORA r E COOLERS OAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS icommerdd) WOODSTOVES
BOILERS FIREP CE INSERTS • GES MISC(Describe)
COMPRESSORS ' ri ACES GAS ' ATER HEATERS
DUCTS - e PIPE OUTLETS
PLUMBING
BATHTUBS torn.b/Shower Combo) SHOWERS - WATER CLOS oaeq MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
IAVS teathroomswra) VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
I cert{fy 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 authorised 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,includin is officers and employees,upon the accuracy of the information supplied to the city as a part of
this application.
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NAME/TITLE -Q.0'yJi DATE
store) (Title)
RELATIONSHIP TO PR ECT a Owner 0 Agent 4Contractor 0 Architect a Other
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Bulletin#100x—January 1,2006 Page 2 of 4 k\Handouts\Permit Application