04-103573 • R F - 41 .0 1/ - / 0 5 513 I,
Federal Way —
PERMIT SF MF CO ME EL PL DEEN 'P
COMMUNITY DEVELOPMENT SERVICES y
33328TH AVENUE SOUTIf•PO BOX 9718
APPLICATION
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FEDERAL WAY,WA 98063-9718
253-835-2607•FAX 253-835-2609 / "'+.....
www.altioffederalway.cram CITY(lc r"rn.-r,a.1
The following is required information-an incomplete ap.Tication will not be accepted. Please print legibly(in ink)or type.
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PROPERTY INFORMATION • ., .
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SITE ADDRESS - I i3'S 2-'C' 1 . 4J2a� 4' S,),,.,1/2-i-, SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# 13 LI 0 / ( C G '--/ 5 I LOT SIZE (sf)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1) S V t 4 1t--'V '')k .T XM 0 tel g'((..)C.1
C St�i— i tip
(Attach separate page or lengthy legal description)
, • t: > «:: >'.. - • PROJECT INFORMATION _ - .
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
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ifitAI,A , ti1..‘ ,`--.e7 5 f`,.$. 14_ C k t.,—k Uc-t J 0 s , )-4...— p A. 6
PROJECT NAME(Name of Business or Owner Last Name) 1/4.3Y 1 G t 2 )S C.-I,LA.k v - Vt,,-} c µ.ms 4-, L�.2
U PEOPLE INFORMATION .
PROPERTY NAME \\ PRIMARY PHONE
OWNER 1"-e-C 2,2.c.‘ ‘J.S r-Ay S c_�..1,J..:I_. ( ) -
MAILING ADDRESS / CITY,STATE,ZIP
CONTRACTOR COMPANY NAME APPLICANT NAME C id ri A-A'- OFFICE PHONE
L3.G -.C_1 k- C L.0 i4`L 14 - c ( 2c;i_) (zL/ s`ZYLi
MAILING ADDRESS ..11 CITY,STATE,(IP CELL PHONE
11() / a,(Z {r� Hak. . .Sec.. (4 ► lv)4 7 /6 ( ) -
CITY OF FEDERAL AY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
_ _ _ / I ( ) -
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CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
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APPLICANT COMPANY NAME APP CANT NAME PHONE
0,,,�. C E',\.(c_,tt, 1 ( -114-4,1.6.5, L„ s-;_,..�, i + .....C:-t_ (`i1> ) 22 46 -`lyQ-s4
MAILING ADDRESSCITY,STATE,ZIP CELL PHONE
(OP/ 1 S G /'dS'1 t a._, `JV\ UJ t4 `7►&.'GS (z(.(. ) Ci( -65-3-o
RELATIONSHIP TO PROJECT - r t FAX NUMBER
El Architect 0 Tenant 0 Agent Other(Describe) -C C lr �, xnJ I(.- (yl , ) 2....,-4.), - '0(17
CONTACT NPRIMARY PHONE E-MAIL ADDRESS
AM1..t il--V J. I ,,,t.. (yL ) L2_,e -'( i'?3
LENDERPer RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP
'.In DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ OC -
SPRINKLERED BUILDING? 0 YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE ❑ TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
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PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
^DECK(COVERED?)
GARAGE/CARPORT /
TOTAL EXISTING
TOTAL.PROPOSED TOTAL ANDEXISTING PROPOSED
HOW MANY FLOORS? XI
“NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIM TED SELLING PRICE $
7.00:;OV:1•04- ,:;.±:--Q;
Ali a [TURES_FD
Indicate number of each type of future to be
installed or relocated as part of this project. Do not include existing fixtures to remain.
V
MECHANICAL
Value of Mechanical Work $
VAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
AIR HANDLING UNITS
BBQS
HOODS(c°mm<m�at) WOODSTOVES
BOILERSFANS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING WATER CLOSETS MISC(Describe)
BATHTUBS(orTob R°�«)/shoo,<rCombo) SHOWERS
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAYS(Bathroom Sulks) VACUUM BREAKERS p� �/E/LECTRIC WATER HEATERS
} r"'li T _ '_xiSCLA MER/SIGNATQREBLOCB. m5zr lr +�,+-` sG 5"r-x000..- .. . ..
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 ma 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 relia ce of the city,including its officers and employees,upon the accuracy of the information supplied to the city as a part of
this application. /�
'pi/ .Gr�� DATE //7 /
NAME/TITLE k.") , 4ck,
(Signature) (Title) � r
RELATIONSHIP TO PROJECT 0 Owner 0 Agent 0 Contractor ❑ Architect `Is7 Other S b C,0"Xl
i
E FOR OFFICE USE ONLY
o NEW ❑ADDITION ❑ALTERATION o REPAIR a'TENANT IMPROVEMENT
. BUILDING SHELL ONLY? o YES o NO BASIC PLAN? o YES ❑NO
i ZONING DESIGNATION CHANGE OF USE? o YES oNO
c NEW ADDRESS REQUIRED? o YES ❑NO UP/SEPA/SU? ❑YES o NO
PLATTED LOT? a YES o NO DEMO PERMIT REQUIRED? o YES ❑NO
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Bulletin 4100—March 30,2004 — Page 2 of 4 k\Handouts—Rcvised\Permit Application