05-104748 �. AECEW
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Federal Way PERMIT
Y OF FED A SF MF CO ME EL PL DE EN P `
COMMUNITY DEVELOPMENT3-971 A LI CATI O N
33325 8TN AVENUE SOUTH•PO BOX 71 ,�
FEDERAL WAY,WA 98063-9718 718 BUILD I N G
253-835-2607•FAX 253-835-2609
WWW LIWat(edelah Catl,rom
The ollowin• is re•uired i ormation-an incom•lete a••lication will not be acce•ted. Please •tint le•ibl (in ink)or ty•e.
• PROPERTY INFORMATION_ _
SITE ADDRESS b( \ 1 P-� 2_ C * &/\-, SUITE/UNIT# -
ASSESSOR'S TAX/PARCEL# _� (J_ _' I_ LOT SIZE// (sf1
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1) -'-e .r�-C2... . �/ ` ru. , S FCT' �� ,
(Attach separate page far lengthy legal descrtptloN ` 1
• PROJECT INFORMATION v
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION ELECTRICAL 0 ENGINEERING IRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit onlO
l Pik• (-NnO ' Ctda\Al-0 v If 0r- -exll9L
PROJECT NAME(Name of Business or Owner Last Name) E�L
-4-s
• PEOPLE INFORMATIONPROPER /1 n
(4._
OWNER TY N f/i( i,' Fe eke Y'TAJ` Lk )la elLtl e. 1157AY NE I
�. CITY,STATE,ZIP
CONTRACTOR MPANY NAME /�/J�� APPLICANT NAME OFFICE
E�PHONE
R S" ��t.' 5 STATE,Z1P CEL`LL HONE - � �
174f t A S c''KC' WA �'/ ( )
C TY FED WAY USINESS LICENSE N MB R EXPIRATION DA FAX NUMBER
� l B iV3 'C' ( )
4ONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
CI ig0_ 52_- K - / /
APPLICANT MPANY NAME e APPLICANT NAME ` OFFICE PHONE
�a ►n W v-t `4t1\ �1 a'01 �( c ) -4&73 2 sCE
LI G ADDRESS ) CITY S TE,ZIP CELL ONE
1745 i sI J . buvq- 615 (z) 3'f9- 5586
RELATIONSHIP TO PROJECT FAX NUMBER r
0 Architect 0 Tenant Agent ❑ Other(Describe) {ZOCO)991 -2s'�/
CONTACT N E c PRIMARY PHONE E-MAIL ADDRESS `
V\CLY .-Ze-1 cc)e.._V`C..0 , (WC,) `t - 52 4)
LENDERPer CW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
( )
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ - VALUE OF PROPOSED WORK $ 0/# Yo°
SPRINKLERED BUILDING? ❑YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
III •
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 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 offixture 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/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
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.c �/ �f/ /�
NAME/TITLE Nj I t t7T �1 �)t/1 �l'G�d nc E L! (CIL(o
( _ ature) (Title)
RELATIONSHIP TO PROJECT ❑ 0 veer Agent Contractor 0 Architect 0 Other
FOR OFFICE USE ONLY
o NEW ❑ADDITION ❑ALTERATION ❑-REPAIR, ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES ❑NO BASIC PLAN? a YES a NO
ZONING DESIGNATION CHANGE OF USE? a YES ❑NO
NEW ADDRESS REQUIRED? ❑YES a NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? ❑YES ❑NO
Bulletin#100-January 7,2005 Page 2 of 4 k\Handouts\Permit Application