05-102745CITY OF AA REC E
Federal Way 1/� AI $E'RMIT
COMMUNITY DEVELOPMENT SERVICES / I N %
33325 81HAVENUE SOUTH • PO BOR 9718 1 aA P P L I C A T I O N
FEDERAL WAY, WA 98063-'7
8063-9 71,x,
253-835-2607• FAX 253-835-26 1 i Y pF F
wwwcitvoffederalway.mm BUILDING p� L WAY
The foilowing is required information = an intete application will not be
SITE ADDRESS
ASSESSOR'S TAX/PARCEL # _
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
(Attach separate pogo far lengft legal d --Poon/
5- - -- 0122YS-7-
rF CO ME EL PL DE EN FP
Please print legibly (in ink) or
SUITE/UNIT t
LOT SIZE (s,)
I -
TYPE OF PERMIT BUILDING ❑ PLUMBING ❑ MECHANICAL
I❑`DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this ermit onl �r--
S, �� ✓9 `� � v—
9
PROJECT NAME (Name of Business or Owner Last Name)
i .
PROPERTY
OWNER
CONTRACTOR
rKIMAKY PHONE
ADDRESS CITY, STATE, ZIP
COMPANY NAME APPLICANT NAME
OFFICE PHONE
MAILING ADDRESS00 CITY, STATE, ZIP
CELL PHONE
CITY OF
FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE -
FAX NUMBER
-B.
— — — — — — L
CONTRACTORS REGISTRATION NUMBER (copy of card required with each appacatiou)
A %��� ��F'
EXPIRATION DATE
J1� -
APPLICANT COMPANY NAME
MAILING ADDRESS
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent
CONTACT NAME
LENDER
EXISTING USE
Aa�l(ry(At3Cgt°Oil&yA` R( y;.
�.�t RYk�`�rt oiR'�A-i'( SI .����S �ihJ.�!S•�(/A=A•.l
EXISTING ASSESSED/APPRAISED VALUE i$_
SPRINKLERED BUILDING? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN
SEWER SERVICE PROVIDER ❑ LAKEHAVEN
APPLICANT NAME OFFICEPHONE
CITY, STATE, ZIP — CELL PHONE
FAX NUMBER
(Describe) .K
PROPOSED USE
VALUE OF PROPOSED WORK7$
FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 17 yEg- gni$-�
❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ HIGHLINE 0 PRIVATE (SEPTICI
7 --
PROJECT
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING
SQ. FT.
PROPOSED
SO. FT.
TOTAL
FT.
BASEMENT
HOODS pom mietl WOODSTOVES
BOILERS
FIREPLACE INSER'T'S"
FIRST
COMPRESSORS
FURPIA
GAS WATER HEATERS
SECOND
3
BATHTUBS (or hth/shows mmol
SHOWERS
THIRD
DISHWASHERS
SINKS
DRINKING FOUNTAINS
FOURTH
SUMPS
RAINWATER SYST
WASE MACHINES
ADDITIONAL FLOORS (DESCRIBE)
HOSE BIBBS
#AVS l6Rth-&.1.1
VACUUM BREAKERS
DECK (COVERED?)
GARAGE ❑ CARPORT 0
NUMBER�°�LOORS
y
riasTiRa
PROPOSED
TOTAL
I TOTAG'E7Ci 6' " r
�,
OTAf ;PROPosED 9F"
IM
AL'er *" ""
r
•`1tl6HOMES ONLY`* 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 fix..[ -td
Value of Mechanical Work
AIR HARbU GIG UNITS
EVAPORATIVE COOLERS
GAS LOGS REFRIG. SYSTEMS
BBQS
FANS
HOODS pom mietl WOODSTOVES
BOILERS
FIREPLACE INSER'T'S"
RANGES MISC (Describe)
COMPRESSORS
FURPIA
GAS WATER HEATERS
DUCTS IPE O0i 'C� ,
3
BATHTUBS (or hth/shows mmol
SHOWERS
WATISR CLOSETS irea�q MISC (Describe)
DISHWASHERS
SINKS
DRINKING FOUNTAINS
GAS PIPEPUTLETS
SUMPS
RAINWATER SYST
WASE MACHINES
URINALS
HOSE BIBBS
#AVS l6Rth-&.1.1
VACUUM BREAKERS
ELECTRIC WATER HEATERS
I certgy under penalty of perjury that the lr{formation 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 Xb� DATE
(Signature) 6�1 u (Title)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑
Bulletin #100 — January 7, 2005 Page 2 of 4 Mandouts\Permit Application