04-105207 RECEI\
C of • ( C �- O 7
Federal Way PERMIT DEC 2 8
211r SF MF CO ME EL PL DE EN e
COMMUNITY DEVELOPMENT SERVICES
33325 8TH AVENUE SOUTH•PO BOX 9718 App LI CAT I �
FEDERAL WAY,WA 98063-97]8 T TD
253-835-2607•FAX 253-835-2609 1 FEDERAL
mmm.attlo/jederahoaq.com IL DINO flrh-
The following is required information-an incomplete ap.lication Will not be accepted. Please .rint legibly(in ink)or type.
•
- • PROPERTY INFORMATION
SITE ADDRESS Z gi-vl C"`"F
ICATI"}1 SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# - LOT SIZE (sf)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal deso-pnon)
•' - ,< •," .-�,t - al PROJECT INFORMATION < ` -
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING X FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
\ -a �... t�a•l ' t I 1La ' C C _.�.\
PROJECT NAME(Name of Business or Owner Last Name) jZighwtpr1., cp./ 3QLIS 4 G-tiu.s C.14)13
• PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER F.g_ tray S )n(m\ ISTR.\GY ( ) -
MAILING ADDRESS CITY,STATE,ZIP
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Ac.Tivc E N&tN 1Na- -eiI6T
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
Sol!o—0-08-8, S'r. S U.) 1- wavmsttia l+J ot°1sd03( ( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
4 O- B L 1z/ 31 /o5 (4Zs)77s ia)Io
CONTRACTOR'S REGISTRATION NUMBS (copy of card required with each application) EXPIRATION DATE
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( )
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect ❑ Tenant 0 Agent 0 Other(Describe) ( ) -
CONTACT NAME' �1 ` , PRIMARY PHONE E-MAIL ADDRESS
M I Qi \v�cwv.\i� W\ �42�'2 b -3„',
LENDER PerRCW 19.27.095: Lender information is NAME Zt: rP 5 71
-44'7
required if project value exceeds$5,000 '
MAILING ADDRESS CITY,STATE,ZIP
;'. DETAILED BUILDING INFORMATION -/
EXISTING USE PROPOSED USE�-�lebt 4G..I K L5 CLQ
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? AYES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER $.LAKEHAVEN ❑ HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC)
• PROJECT FLOOR AREAS•
AREA DESCRIPTION EXISTING SQ. FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE) •
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS? TOTAL EXISTING TOTAL PROPOSED TOTAL EXISTING AND PROPOSED
"NEW HOMES ONLY*A NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
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(commermal) 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(rode) 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
{-,::0 ¢S 4 "V 4 r V . xDISCLAt R/SIGNATQREBLOCK-- - s`= ;=�r .` . - - -
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. �p� at2141)........UPLAt// *L""" DATE / .—p�8'07NAME TITLE �(Signal (Title)
( RELATIONSHIP TO PROJECT 0 Owner ❑ Agent )(Contractor o Architect 0 Other
i
f
E FOR OFFICE USE ONLY '
a NEW ❑ADDITION ❑ALTERATION o REPAIR a:TENANT IMPROVEMENT
i BUILDING SHELL ONLY? o YES Cl NO BASIC PLAN? o YES o NO
I ZONING DESIGNATION CHANGE OF USE? o YES a NO
NEW ADDRESS REQUIRED? a YES a NO UP/SEPA/SU? a YES o NO
PLATTED LOT? ❑YES o NO DEMO PERMIT REQUIRED? a YES o NO
Page 2 of 4 k\I Iandouts-Rcvised\Peanit Application
Bulletin[1100-March 30,2004