05-103754 ,�A dc- 1._ Qi 2
Federal W ECEVD PERMIT
, ,MEM SF MF ID L PL DE EN FP
A L W 98 -97 L 2 8 2oo5APPLI CATI O N
253.835.2607•FAX 253-835-2 irD
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The ollo„ :I�`FEDERALWn-an , , ' ,-late ,licnttonwill not be ---, ' Please • r • . , • , • or ., - -
• PROPERTY INFORbMATION ,
SITE ADDRESS �J'/ /1 '/ si 1 / Ctitti
(w) G�i0'- r 0 C)g SUITE/UNIT I
ASSESSOR'S TAX/PARCEL# / L 5 5 / - O 9 G/ 0 LOT SIZE(s)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach aepruate page for lengthy legal )
all PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING � CCHAIICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
Ren a M.ptaC 54a Rex- e/r(-
U! 0724- 0� 45 �7t'5 ( ) a -�—
PROJECT NAME(Name of Business or Owner Last Name)
P>rt--72--
MI
q PEOPLE INFORMATION
PROPERTYPRIMARY
OWNER NAME l .LL �I `2( � /�"L - (j5 )`� �O� -`r C/
5/ADDRESS Cf 'fS 3
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
U,,)(4i �e,& ti.ic �-k(A!k4: (ti „. C o (` )`�l-�, -�55`
MAILING ADDR� CITY,STATE, CELL PHONE
5-1 0 6 )C,3-" \-C-4- 5 \At )c-:,-c.\ v--i-z `k&r 1 (•47.5) S1 -`1`15 k`6
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
(2 5_—L Q-5. 5. Z o_-s L /Z / 5, /Z� l' (-4,1 3n - -N5y
CONTRACTORS REGISTRATION NUMBER(copy of card required with each application) TION DATE
(,v & - - el '6_ CL U p //7 /U�
APPLICANT C MP NAME / APPLICANT NAME // OFFICE PHONE
�'66 „MAILING 1 Wt.':1 :,' t'u ,zS ( 1 t 711 n L`-6,'c°`-- ( YI )` r7t5 - .
ol75 56¢" 5 fPHONE
tbL'i1 iLi.�. 186)6/ ( t/Z5) 3 7' -"Is'/1`l
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect ❑Tenant ant 0 Other(Describe) (S ) 3-7.5 - 2Y5/
CONTACT Tar PRIMARY PHONE
C-0 a.„,.. (` ) 617S - 5b .1 eh
he -�
yLipt.cL\c,1t
LENDER Per RCW 19.27.095: Lender in/brntatlon is NAME 0(
required if project value=eases 05,000
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
=STING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? 0 YES .❑NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO n
WATER SERVICE PROVIDER 0 LAKEHAVEN ❑ HIGHLINE 0 TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN a HIGHLINE 0 PRIVATE(SEPTIC)
PROJECT FLOOR AREAS
•
— AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED?)
GARAGE 0 CARPORT 0
COMM
NUMBER OF FLOORS reorosea TOTAL TOTA
L T O SAL PUG otn r TOTAL IR
**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.
,ate � (1—C1Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS rc.mmerci.q WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES / GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING?
BATHTUBS(orThb/Sh.wer C.mbo) SHOWERS WATER CLOSETS(roue) MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS Ie•wr••m SvJm) VACUUM BREAKERS M.ECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the information fiurnished by me is true and correct to the best of my knowledge,and further,that I
am authorised by the owner of the above premises to perform the work for which the permit application is made. I,Mather agree to hold
harmless the City of Federal Wm as to any claim(including costs, expenses,and attorneys'fees incurred in the investigation and defense of
such claind,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. �( f
NAME/TITLE J U Cl - A^M� (S (- ( &ATE 1 / 2��O S
6Signature) (ritic)
RELATIONSHIP TO PROJECT O Owner Agent ❑ Contractor 0 Architect 0 Other
FOR OFFICE USE ONLY
a NEW a ADDITION ❑ALTERATION ❑REPAIR ❑TENANT IMPROVEMENT
BUILDING SHELL ONLY? n YES a NO BASIC PLAN? ❑YES ❑NO .
ZONING DESIGNATION • CHANGE OF USE? a YES ❑NO
NEW ADDRESS REQUIRED? ❑YES a NO UP/SEPA/SU? a YES ❑NO
PLATTED LOT? o YES ❑NO DEMO PERMIT REQUIRED? a YES o NO
Bulletin#100—January 7,2005 Page 2 of 4 k Handouts\Permit Application