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CITY OF EPMT ,� —.1111
Federal Way RECEIVE PT —" — — -- -=
COMMUNITY DEVELOPMENT' SF MF CO ME EL PL DE E ' FP
33325 8tN AVENUE SOUT1-918.:603 BOX 9718 o v oAPPLICATION FEDERAL WAY,WA -8 -9718 TD / i- /
253-835-2607•FAX 253-835-2609
vix9 ik,
www.cityoffederalway.corn
)TY OF FEDERAL WAY
The olloudn. is re.uireg P • tERTan •co,k.tete a..lication will not be acce.ted. Please .rant le.,ibl (in in or .e.
IN. PROPERTY INFORMATION •
SITE ADDRESS
d S/�
-7 SUITE/UNIT#
fY .,� ,S, <?,1:i,�
ASSESSOR'S TAX/PARCEL# - LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal descaiption)
.. ~.110 PROJECT INFORMATION •
TYPE OF PERMIT ❑BUILDING 0 PLUMBING ❑ MECHANICAL
0 DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING R FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
•
PROJECT NAME(Name of Business or Owner Last Name) "— ../......,,_6 L�}y c.,f-y1.,,�;,�,,‘ 6-,t,,/t-AL
171 PEOPLE INFORMATION •/
PROPERTY NAME
PRIMARY PHONE
OWNER -.l._ C- C-( 0 r?c A-4-1 s`N. tY ( ) -
MAILING ADDRESS CITY,STATE,ZIP
CONTRACTOR COMPANY NAMEy�y-- APPLICANT NAME OFFICE PHONE
At OPil9-/zC:1 Lab+os*,, eu,., 71L',Gc.t-;4,- (21j ) 92.4 - /7 y'
MAILING ADDRESS -. - CITY,STATE,ZIP CELL PHONE - -
S-C)t 7 A.,y.---, lft..,y G e 14-"!":'-C--- Z, e.a. el,Y1 Y (2-:1 ) 2J, /J-9/
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
-g L / / ( ) -
CONTRACTOR'S/ ✓
REGISTRATION NUMBER(copy of card required with each application( EXPIRATION DATE
/1470 k" 4"— / t- / , L1 7 / / -..f/ /C¢ (.
APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
RELATIONSHIP TO PROJECT FAX NUMB ER
❑ Architect 0 Tenant ❑Agent 0 Other(Describe) ( ) -
CONTACT NAME PRIMARY PHO E _
�.� � E-MAIL ADDRESS
--t tN1;1_rs--C-},--' (% s3) 21i- 19
LENDER 's o "` er o:: n'VA
NAME
,,,w n ! .?e 4 m ',:Z.h .b'ES J cA $n {k 'S. iV., II 6:::<........_
MAILING ADDRESS CITY,STATE,ZIP
. \ DETAILED BUILDING INFORMATION ` .
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ /C1 tVT' ,
SPRINKLERED BUILDING? ❑ YES 0 NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES 0 NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
•
PRO.,,a c, T FLOOR AREAS
AREA DESCRIPTION s - EXISTING PROPOSED TOTAL
SQ.FT. SQ. FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
•
DECK(COVERED?)
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL TaP.cf^L7Q§3'DP6 F TAL PROPOSED 9F �. ,u;ar?"
NUMBER OF FLOORS , ' , I=:
Wi .. z
**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(Toile) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(bathroom Sulks)
V:CUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the in . ation 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 S not e / ✓�� DATE // _. 9 Ui
( I (Title)
RELATIONSHIP TO PROJECT ❑ O ❑ Agent Contractor ❑ Architect 0 Other
—
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0` t $u Aix e D ( ,� _a a .,n® .mm E „�. @ �� ,i ` ,, •a� 'ir
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Bulletin#100—January 7,2005 Page 2 of 4 k\Handouts\Permit Application