05-102740 City of Federal Way Mechanical Permit #: 05 - 102740 - 00 - ME
Community Development Services i
P.O.Box 9718
Federal Way,WA 98063-9718 I -
Ph.(253)835-7000 Fax (253)835-2609 Inspection request line: (253) 835-3050
Project Name: VAN DER ROEST
Project Address: 30224 1ST S Pt- Parcel Number: 339180 0200
Project Description: Installing wood burning stove
Owner Applicant Contractor
Raymond Daniel Van Der Roest Raymond Daniel Van Der Roest Raymond Daniel Van Der Roest
30224 1ST PL S 30224 1ST PL S 30224 1ST PL S
FEDERAL WAY WA FEDERAL WAY WA FEDERAL WAY WA
98003-4037 98003-4037
Mechanical Valuation 2415.98 Over the Counter Permit Yes
Mechanical Fixtures
Description Quantity Description Quantity Description Quantity
1 Woodstoves 1
I
PERMIT EXPIRES December 7,2005.
Permit issued on June 10,2005
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and the use will be in accordance with the laws,rules and regulations of the State of Washington and
the City of Federal Way.Owner or agent: Lhj2 LJt�L6FDate: �6/ga
NoeN
F�
0 (-)
THIS CARD IS TO REMAIN ON-SITE
CITY OF Community Development Inspection Record
Federal Way IVR INSPECTION REQUEST PHONE # (253) 835-3050
PERMIT#: 05-102740-00-ME
Owner: RAYMOND DANIEL VAN DER ROEST
Address: 30224 1ST PL S
FEDERAL WAY, WA 98003-4037
This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD.
Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not
be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence. On-going inspections
are logged on the back of this card.
0 Mechanical Rough-in (4165) ❑ Gas Piping(4125) 0 Final-Mechanical(4065)
Approved Approved to release test Approved
By Date By Date Date '?--c,
A REGENED . . .
Federal WayJUN 0 X005 05- I2 7s v
CUMMUNTYDEVELOPMENT SERVICES Y P E R M I fi
3332;DW •Ysolrnf 7 pie FEDEREPT A SF MF CO L PL DE EN FP
253-83S-2607•FAX253d35 ILDING DEPT CATI O N
www.dtaolred_niwou••N- /
The ollowi • is re• ired in ormation-an •• •fete . • •lication will not be acce.ted. Please .rint le• •1 in i or
111 PROPERTY INFO/RM( [,(J //
ATION �
SITE ADDRESS --:)...)0-2,311 To )2k P( c-43-0 �C(�O SC•3 SUITE/UNIT I
ASSESSOR'S TAX/PARCEL 41 -
LOT SIZE(si9
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
Attach a arp efirIepayflegaldesoipaon)
—
gI PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING "MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
j-rn5 arnr\S C_Q X5DCA lOti T fl
5 $17-5-u-e— .
PROJECT NAME(Name of Business or Owner Las N. e) VAA.44 I)e PEOPLE INFORMATION ?.....0e54-
14PROPERT /` {� PRIMARY PHONE
OWNER
KA-7(.-1! r IU► ►A ��CQ�1 Ger 2C) \ (.253)529 -5302
DDRESS CITY STATE,ZIP
Za y I C CITY,
we ° g0o3
CONTRACTOR PANY NAME t/ J r (� APPLICANT NAME OFFICE PHONE
� � VIJUV () [ll� AT,R, ( )
I.INO( ES3
2g Li l =eiecal CELL )71k - (S-77-
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE FAX NUMBER
B L / / ( ) -
CONTRACTORS REGISTRATION NUMBER(copy of card regal/7A with each application) EXPIRATION DATE
/ /
APPLICANT COMPANY NAME
Alt APPLICANT NAME OFFICE PHONE
MAILING ADDRESSCOWL- - )
CITY,STATE,ZIPCELL PHONE
RELATIONSHIP TO PROJECT FAX NUMBER
0 Architect 0 Tenant ❑Agent 0 Other(Describe) ( ) -
CONTACT NAME ' `� PRIMARY;HONE - E-MAIL ADDRESS
LENDER W 11
'>.- :d;lt' • 'i., �frt;� u�l r:7�:� 7%"jf f'r,v,f:Y,!„ x; NAME
MAID r ADDRESS CITY,STATE,ZIP
• • DETAILED BUILDIititi INFORMATION .
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APP v. - - a UE $ -- • PROPOSED WORK $
SPRINKLERED BUILDING? 0 YES 0 NO -.-' . i " __ a . YSTEM PROPOSED/REQUIRED? ❑YES a NO
WATER SERVICE PROVIDER 0 i i • VEN ❑HIGHLINE 0 TACOMA a PRIVATE(WELL)
SEWER SERVICE PROVIDER 0 LAKEHAVEN 0 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
EXISTIRoPROPOSED
NUMBS: • re ORS I � *
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be instale. .r -located 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(Cammercus WOODSTOVES
BOILERS • FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(orTub/showerCamb*) SHOWERS WATER CLOSETS(caws MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Staka) VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMIER/SIGNATURE BLOCK
I certify under penalty of perjury that the ormation 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/TITL �� t v !/ / �! / DATE //U/w
(Signature) (Title)
RELATIONSHIP TO PROJECT "Owner ❑Agent 3"Contractor 0 Architect 0 Other
h5):' :ur7;)J't`(e)j( +t'0D};e,F.1'(e,) �, � tVI:;I •,t' 4-Vl°t' Xii.) (C «�!,I tt_t.
• ie;ir,aWee,.0;e:AIL ei;€ir ) ::. �(c ,q:Kc)(c',a[ �; '1� ) 40
i;(i;tc e,)a.`iie 6t't?Zc� 1 €.cYt✓�` c 5, i y; :.�� to . ..._ -.
,vI)ift14 i ;)�oar(i;»tiy 'n::i -;(61 .{,r -I. 7fJ Dr:: e~
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Bulletin#100—January 7,2005 Page 2 of 4 k\Handouts\Permit Application