04-104625 � REC . VED 1s°2/2 " q_ - ( O (o z,„,
Federal WayR
PE MIT SF MF CO ME EL PL DE ENI
COMMUNITY DEVELOPMENT SERVICES Nov
V 1 2 2 4 '
JJ32F 8T"AVENUE,WA •63 BOX 9719718 A p L I CATION
FEDERAL WAY,WA 98063-971 B iD ]J���
253-835-2607•FAX 253-835-2609 CITY OF FEDERAL WAY / /
mwm.dtyolTederalte.atl.rnm
BUILDING DEPT,
The following is required information-an incomplete cep.lication will not be acce'ted. Please •rint legibly(in ink)or type.
' --. C MI PROPERTY INFORMATION
SITE ADDRESS 2 7 5 00 7 -Ce L A 76
Lt,,.)G 5v /&.6 3 SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# _ _ LOT SIZE(sf)
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Attach separate page f lengthy legal desoipfion)
IN PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING JK FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of , 12.e. on . ,f_-_ it onl
„„t v`J 1,411 D-1) a a ,_w/ �).r rrs� 5' 31 � �.t•r ..41.4......".•..41.4......".• 2 A�S 4.--J q
�•'.t✓,_57_,,k.,.._ �
v.Gr7 % rS � , ✓a A.<,t .
PROJECT NAME(Name of Business or Owner Last Name) Alio 2j.._
is PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
OWNER Itip 2_a•-. (CIO l ) 415 - ((az..
MAILING ADDRESS CITY,STATE,ZIP
123 s,. (, fro.. 54 .E _ 1."s TN 3$w 3
CONTRACTOR COMPANY NAMEAPPLICANT NAME OFFICE PHONE
s MAILING ADDRESSiS SG I4
CITY, a ZIP / 1 CELL`5j )NL(- ' i 2.
E
Po Soxo . ce, (z,. ) 3q-)- -972,7,
CITY OF FEDERAL WAY BUSINESS CENSE NUMBER EXPIRATION DATE FAX NUMBER
-S 1 -1 0 6 c6 s s -B L / (2-53) tf73 - '1552_
CONTRACTORS REGISTRATION NUMBER(copy of card required with each application' EXPIRATION DATE
I /
APPLICANT COMPANY NAME�c II APPLICANT`�NAME 1 OFFICE PHONE tri.3- )Z
S TJ Sew(;'t a Vr..A.tf. ( 2_53) -
MAILING ADDRESS - CITY,STATE,ZIP CELL PHONE
90 T&:..)‹ 106(., Ike-,. .,a �L-ikk 4M,i09 ( 2-53)371- -41-22
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect 0 Tenant 0 Agent (Other(Describe) C_. f a r?), (2. J) 111.3 - `t s5 2
CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS
E1 f ( 253) 3/1--91-21_ 6b.�e yC� �{otjej
LENDER -; per CW 9•27095'e�iriformationis ;9 NAME t
required if project value exceeds$5,000
MAILING ADDRESS w CITY,STATE,ZIP
' : ■ DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ k„/r,00
SPRINKLERED BUILDING? RYES a NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? YES a NO
- WATER SERVICE PROVIDER 0 LAKEHAVEN ❑HIGHLINE ❑TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER a LAKEHAVEN o HIGHLINE 0 PRIVATE(SEPTIC)
. • • • PROJECT FLOOR AREAS
... �� —r– _ SED SQ.FT. TOTAL
AREA DESCRIPTIO EXISTING SQ.FT.
P' •
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIBE) _•.
DECK(COVERED?)
GARAGE/CARPORT
TOTAL EXISTING TOTAL.PROPOSED TOTAL EXISTING ARD PROPOSED
HOW MANY FLOORS?
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
_ : y :FUTURES
Indicate number of each type offacture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $
EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
AIR HANDLING UNITS
BHOODS(commerciaq WOODSTOVES
' FANS BOILERS FIREPLACE INSERTS RANGES MiSC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING WATER CLOSETS Roucq MISE(Describe)
BATHTUBS or run/Shower Combo' SHOWERS
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sinks) VACUUM BREAKERS ELECTRIC WATER HEATERS
' 2 = _;DISCLAIBIER/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 bo,person,including the undersigned,and filed against the City of Federal Way,but only where such claim
arises out of the reliance of the c ncluding its officers and employees,upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE DATE I IL c 1
/r ignaturd critic)
f RELATIONSHIP TO PROJECT//10 wner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
I
IFOR OFFICE USE ONLY
'
a NEW o ADDITION a ALTERATION ❑REPAIR a TENANT IMPROVEMENT
i BUILDING SHELL ONLY? a YES ❑NO BASIC PLAN? o YES o NO
1 ZONING DESIGNATION CHANGE OF USE? o YES a NO
I. NEW ADDRESS REQUIRED? o YES a NO UP/SEPA/SU? a YES o NO
PLATTED LOT? ❑YES a NO DEMO PERMIT REQUIRED? o YES a NO
f
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Bulletin#100 ch 30,2004 _ Page 2 of 4 k\Handouts—Rcvised\Permit Application