05-102468I
CRY.
APPLICANT NAME
Federal Way
PERMIT
COAfb1UNRYDEVELOFIIF.R1'S6RVEC
nY 2 5 2005
ssszs�A��E�,'FaX, MPLICATION
FEDERAL WAY, WA 98063-9718253esss6ous'TY
U(Ayeg
OF FED ER
, STATE, ZIP
SUILDWG DEPT.
The following is required
information - an incomplete application will not be at
SITE ADDRESS
ASSESSOR'S TAX/PARCEL # _
LEGAL DESCRIPTION (e.g. Atone Estates, Lot 1)
l!i: -Lv_z_�i(2-- �(
SF MF CO ME EL PL DEE FP
pied. Please print legibly (in inkl or t -am
0
SUITE/UNIT #
J -OT *ZE (sp A
PROJECT•- •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT NAME (Name of Business or Owner Last Name) &i'e- Y�
PEOPLE•• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
MAILINO ADDRESS CITY, STATE, ZIP
COMPANY NAME
APPLICANT NAME
APPLICANT NAME
d1w
OFFICE HONE
OFFICE P ONE
re 157&7
U(Ayeg
MMMLINO DRESS
, STATE, ZIP
MAIUNO ADD
CITY, STATE, ZIP
CELL PkIONE
RELATIONSHIP TO PROJECT
FAX NU ER
❑ Architect ❑ TenantXnt ❑ Other (Desabe)
_
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE
�O�3
I�
- --B L.
3-V
CONTRACTOR'S REO RATIrON B
(eoP7 of card req with each apppLLeation)
EXPI TIONDATV
/.:;!>0 /O
"
—
COMPANY NA
APPLICANT NAME
OFFICE HONE
—
0
MMMLINO DRESS
, STATE, ZIP
CELI N�
)
RELATIONSHIP TO PROJECT
FAX NU ER
❑ Architect ❑ TenantXnt ❑ Other (Desabe)
)-20-C)/
PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK S$ Amw
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN O HIGHLINE O TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE 0 PRIVATE (SEPTIC)
AREA DESCRIPTION
EXISTING
Q.. FT.
PROPOSED
SQ. FT.
TOTAL,
SQ. FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK (COVERED?)
GARAGE El CARPORT ❑
NUMBER OF FLOORS
1' NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
pw i vj uua pruJ6Cl i not vtctuae extsnng Jvetures to remain
AIIE
CAL
Vaht I o Mach b,01
Value of Mechanical Work $ ..�� ,„� /•
AIR HANDLING UNITS EVAPORATIVE COOLERSGAS LOGS G.SYSTEMS
BBQS FANS HOODS (cone ci.q WOODSTOVES
BOILERS FIREPLACE INSERTS
RANGES MfSC (Describe)
COMPRESSORS FURNACES OAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
BATHTUBS (or Tub/stawarcomba) SHOWERS WATER CLOSETS goiwq MISC (Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS (m th- m.� VACUUM BREAKERS ELECTRIC WATER HEATERS
t cert(& under penalty of perjury that the Wormation 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 ir{formation supplied to the city as a part of
this application.
NAME/TITLEOA DATE�U
(Title)
RELATIONSHIP TO PRO,)❑ Owner ❑ Agent n ctor ❑Architect ❑Other
Bulletin # I00 — )anuaiY 7, 2005 Page 2 of 4 k\Handouts\Permit Application