04-103432 CITY Of 403111.44.411111111
Federal Way • r�, - -LO_ 3 V3
COMMUNITY DEVELOPMENT SERVICES
PERM I �- RECEIVE F MF CO ME EL PL DE EN�'�J/1
33325 ST"AVENUE SOUTH.PO BOX 97I8
FEDERAL WAY, APPLICATION
N 2 72(-
253-835-2607.
-
p /
253-835-2607•FAX 253-835-2609
uru,u,.dh/o((ederalu,a y.mm
The following is required information-an incomplete ap.licatid'>� d,1 be accepted. Please print legibly(in ink)or type.
. yy C •. M PROPERTY INFORMATION
SITE ADDRESS 3 14 S �— 7/4 V L C5 ,
SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# - LOT SIZE (sf
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
/Attach separate page f lengthy legal description)
z .., PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
0 DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING , FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu) ///
U 7�i291�T/C� t et r _57/212_/Ai lc CC-4J
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PROJECT NAME(Name of Business or Owner Last Name) BO,/S i t („$ C• C3 (Pco 14s "_
MI PEOPLEINFORMATION
PROPERTY NAME
,��, /� PRIMARY PHONE
OWNER 1�.�-"�S �' C.JZ//eCs G- i3 Cil /.<04C7 (U , ( ) -
MAILING A DRESS CITY,STATE,ZIP
CONTRACTOR ,..),c7A NY tt .AP ;tlti/U6t 4/t I NAME FFICE P)ONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
/ CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
— — B L )
CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
ADiV6aFn ? 6 (c /a. / 3/ /cy
APPLICANT CO/M�PANY NAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS !w/ `-' �iv (c(� ���l,"7�L � � 1
CITY,STATE,ZIP CELL PHONE
/175 , /
( Il�GUG3PIrrvl�(c- V�ll4, `l 8077._
RELATIONSHIP TO PROJECT /
FAX NUMBER
0 Architect ❑ Tenant prAgent 0 Other(Describe) ( 'z;1'E3 3
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
jC. ���:-(Z.C� Z z& -L 7� ( ZJ 3) Co3q �L c.-0/0
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 gCyi ?- 611 re(---S. �L csj3
EXISTING ASSESSED/APPRAISED VALUE $ p0
VALUE OF PROPOSED WORK $ G �/ 7�'7
SPRINKLERED BUILDING? ';,1 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? XYES ❑ NO
WATER SERVICE PROVIDER KLAKEHAVEN O HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
M.
•
PROJECT FLOOR AREAS .
AREA DESCRIPTION EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
OC 0 /6Po
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
TOTAL EXISTING TOTAL PROPOSED TOTAL EXISTING AND PROPOSED
HOW MANY FLOORS?
"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.
ValuCefof Mechanical Work $ 1(O, 7 8
AIR
GAS LOGS REFRIG.SYSTEMS
HANDLING UNITS EVAPORATIVE COOLERS WOODSTOVES
BBQS FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
HOODS(camm<rd�I
RANGES X MISE(Describe)
BOILERS GAS WATER HEATERS FIRE ��/���(�q�
COMPRESSORS
DUCTS
PLUMBING WATER CLOSETS Rou�q MISC(Describe)
BATHTUBS(or Tub/ShoucrCombo) DRINKING FOUNTAINS
RAINWATER SYST
DISHWASHERS SINKS
SUMPS
GAS PIPE OUTLETS HOSE BIBBS
ELECTRIC WATER HEATERS
WASHING MACHINES URINALS
LAVS leau,rooms;r,>«I
VACUUM BREAKERS
..r 1 _ �i -:DISCLA�+Rf►S !".-.-:-..2;.-:..-.,,-7---_-;
... _ _ _
IGNATIIItEBLOCH
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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.
g
. DATE IS'"Z7 r 0NAME/TITLE �� 0,„„....,,,,
(Title)
(Signature(
i RELATIONSHIP TO PROJECT 0 Owner Agent ❑ Contractor ❑ Architect ❑ Other
E FOR OFFICE USE ONLY l
o NEW ❑ADDITION a ALTERATION a REPAIR oTENANT IMPROVEMENT
o YES ❑NO
BUILDING SHELL ONLY? o YES o NO BASIC PLAN?
CHANGE OF USE? ❑YES o NO
i ZONING DESIGNATION 1
t NEW ADDRESS REQUIRED? ❑YES ❑NO UP/SEPA/SU? a YES ❑NO
PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? o YES o NO
J
Bulletin#100—March 30,2004 — Page 2 of 4 k\I Iandouts—RcvisedWermit Apction