04-101027 RECEIVEDCOMMUNITY DEVELOPMENT SERVICES
41,._ 33530 FIRST WAY SOUTH•PO BOX 9718
art of�,.. ...
�. FEDERAL WAY,WA 98063-9718
Federal W AR 2 3 2004 P RMIT APPLICATIO 53b6T4IT5•PAX.253-66T4129
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For... 00.3(.0F F---,! — r — f )- TD:
• The ollowin. is re.uired in ormation-an incom•fete a.•lication will not be acce•ted. Please .rint le•ibl (in ink)or .e.
p /� ` ■ PROPERTY INFORMATION •
SITE ADDRESS: -ter-' 1' / IVe •
(5, SUITE/APT#
ASSESSOR'S TAX/ARCEEL'# 3 0 j 5 I - o G L 0 SQUARE FOOTAGE OF LOT:
LEGAL DESCRIPTION (e.g.:Acme Estates,Lot 1)
(Attach separate page for lengthy legal description)
■ PROJECT INFORMATION
TYPE OF PERMIT(This application): ❑ BUILDING 0 PLUMBING ❑ MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING[FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only):
.II
eat 01 a (a 0'Ai
AaC15---(1S—nef-Olth h reKICriel And Me() ( 31
•PROJECT NAME(Name of Business/Owner Last Name): j, i•/, t 1 0,I - n9 j, f i f' 0,1 I
• PEOPLE INFORMATION
PROPERTY NAME: frinci3
Rtot n�j�/� �/ C �f�n PRIMARY PHONE:
OWNER 6e 1 A-& A-s11./lil. - (MAILING ADDREEET ADDRESS;): CITY,STATE,ZIP,
411111 _
CONTRACTOR NAMF\tiCOMPANY OFFICE PHONE:
Y10 VQ �C( P� (�25 g ZZs o
MAILING ADDRESS(STR ET ADDRESS;): CITY,STATE,ZIP CELL HONE:
(A53)q22- -6,t
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: EXPIRATION DATE: FAX NUMBER:
I g- 9 i-Lo L qS8- @c— ?/' \ /OA
CONTRACTORS REGISTRATION NUMBER: D a 1 /� EXPIRATION DATE:
(copy of card required with each application) r Py� I E a Q 63 /� / Cr C v / < /@(/
LENDER NAME: DAYTIME PHONE:
(If Proposed Valve>$5,000) ( ) _
MAILING ADDRESS(STREET ADDRESS;): CITY,STATE,ZIP
APPLICANT: NAME: ANY OFFICE PHONNE:7fil(tpr/kt O oG / (253) gm, -22-q0
MAILING RECITY, ZIP
27c 1 I (
TO li' Ale 6 --rap A r olio 1 J is I-y OJECT: FAX NUM)RELAER:
❑ Architect ❑ Tenant ❑ Other(Describe): j(p )6?22_ - (of SC
CONTACT PERSON FOR THIS PROJECT: ❑ Property Owner 0 Contractor 0 Applicant I jj E � �/�
�„1-.�'�
• ■ DETAILED BUILDING INFORMATION U I T 1 l c: !
• EXISTING USE: PROPOSED USE: /��/y�
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK: $ z22
SPRINKLERED BUILDING? ❑ YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED?: ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
■ PROJECT FLOOR; AS
AREA DESCRIPTION EXISTING SQ.FT. PRO•• ED SQ. FT. TOTAL
BASEMENT
FIRST
SECOND J •
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS? TOTAL EXISTING TOTAL PROPOSED TOTAL EXISTING AND PROPOSED
['NEW HOMES ONLY`* NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
■ FIXTURES
Indicate number of each type of fixture that is 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(commeee al) W OODSTOV ES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or Tub/Showercombo) SHOWERS WATER CLOSETS(roue) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYS411)
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathraom Sink 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: DATE: 3 23/(!7
4 ::::0"/(Signature2.-13
(Title)
RELATIONSHIP TO R JECT: 0 Property Owner 0 Applicant ❑ Contractor 0 Architect 0
FOR OFFICE USE ONLY:
❑NEW o ADDITION ❑ALTERATION o REPAIR o TENANT IMPROVEMENT
BUILDING SHELL ONLY? o YES o NO BASIC PLAN? a YES o NO
ZONING DESIGNATION• CHANGE OF USE? ❑YES a NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? o YES o NO
Ikt CL:"I •ail;% _._.. _ .ri
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