06-103097 unoF A RECE`ED /j - f O y O 7
Feder�alWay 6p ERMIT 1� ``��
COMMUNITYDEVELOPMENT SERVICES JUN 2 1 200 SITDF MF CO ME EL e1/DE EN FP
333?SQn+AVENUE WAY, ATTI.PO BOX 9718 �,A I CAT I 0 N
FEDERAL WA 94063-9714
253-83sz607•FAX 253435-2609 OF FE
...
wuw.dtuotTederahuau.alm BUILDING DEPT.
The ollowi • is re•aired in ormation-an inco •lete a• •lication will not be ecce•ted. Please •rint le•ibi in in or • .
• PROPERTY INFORMATIO�1N-
SITE ADDRESS 370 5(L) 326 -, SI- ( d. C��( SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# - LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal deeaiplan)
• PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING /PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provided ailed description of work included on this permit only)
F� /e-evi 0 rid-4
PROJECT NAME(Name of Business or Owner Last Name) SILM ( N
• PEOPLE INFORMATION
PROPERTY NAME -^^ PRIMARY PHONE
OWNER S GOet(n ( 260) 79' - 92sb
MAILING ADD S CITY,STATE,ZIP
ked, ey( AJA
CONTRACTORCOMPANY NAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
( ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER ,�p , EXPIRATION DATE FAX NUMBER
- - -B 'L Lt-IV( 67 /2( IE'CP ( ) -
CONTRACfOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
.l-L►1 & I( yT c 0t fiA- l20 / o?
APPLICANT COM ANY NAME APPLICANT NAME OFFICE PHONE
���-; „h I"LPI4� �% , (27/,/,e..-N— . ( ) y3g -c 0�
MAILING ADDRESS CITY,STATE,pP CELL PHONE
t D, 60)e- 7oi &.1/v ,,,,,� udf 96,57e(g6o) w
RELATIONSHIP TO PROJECT // FAX NUMBER
/'
0 Architect ❑ Tenant 0 Agent ❑ Other(Describe) l�Ie-4-- (360) 53g -3383
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
( .) -
LENDER NAME
MAILING ADDRESS CITY,STATE,ZIP PHONE
( ) -
■ DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ •
SPRINKLERED BUILDING? d YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑YES 0 NO
WATER SERVICE PROVIDER 0 LAKEHAVEN a HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
11, II
PROJECT FLOOR AREAS
_
i
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD 1
FOURTH
•
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE 0 CARPORT 0
=ATM PROMS= TOTAI. '
NUMBER OF FLOORS
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECFIANICAL
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 •
2 BATHTUBS forms/sit...,Combo) 2 SHOWERS I ,3 WATER CLOSETS(rennet) / MISC(Describe)
I DISHWASHERS / SINKS)G4'1 DRINKING FOUNTAINS ((jr- -
GAS PIPE OUTLETS SUMPS RAINWATER SYST
I WASHING MACHINES URINALS 2-- HOSE BIBBS
II LAVS(Bathroom s; VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
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. / y /
NAME/TITLE t)�� /C/)/Vier /69/9Y-7. ")/G , •?,. .isi,:iil�iDATE 6 A/` U
��
(Signature) g 124/ 1
RELATIONSHIP TO PROJECT 0 Owner 0 Agent ❑ Contractor ❑Architect ❑ Other
1
Bulletin#100—January 1,2006 Page 2 of 4 k\Handouts\Permit Application