04-104505 /d- fSa3(
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Federal Way — — (/ 50 S
Nov o 4 2004
dpOMMUNITY DEVELOPMENT SERVICE SF MF CO ME EL PL DE ENelD
33325 31'-'AVENUE SOFAX TH25•PO BOX 9718 0 L I C A T I O N TD
FEDERAL W.AI',WA 9806397�.q� Y OF FEDE
253www.itgo FAX os(TBUILDING
www.cihioffederojwag.com I / / -.
The ollowin. is re.uired information-an incom•lete a'•lication will not be acce.ted. Please •rint legibly in ink or t •e.
7 l�-) • (PROPERTY INFORMATION
SITE ADDRESS 3) L'5 3 rat_( v q►1W S, s-L �!� // SUITE/UNIT# i >
ASSESSOR'S TAX/PARCEL# 0 81 Q I 0 - el 1 ( to LOT SIZE (sf)
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1) P&L,l i O v\ C e i, -Ce, (( ( ci )
(Attach separate page for lengthy legal description) ``1
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING ❑ MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING , ,FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit onlu)
lAX,'.�V\c,kS -k-Dr. hem t,J y d Ce( Iinr
Z$
PROJECT NAME(Name of Business or Owner Last Name) r s;tl, . 1--k_ 1._
• PEOPLE INFORMATION
PROPERTY NAME PRIMARY PHONE
I C
OWNER ��Vs4"\ aAUtrd1� Jpb ✓;ray
i (J� )t '� p� �(�
ING ADDRESS CITY,STATE,ZIP
i I a I sw &QW\o IN s4-. R.A,.,4, o 2 ao 3
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
Pat;nk--- Rrt._Prb \nr\,Srnc. JO‘olin 6a CC e--- (c>/..:1.3) 9a6 - . a(F0
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
>r-f? .)t)
A . C, 76icokmek. LA)IA elh(-(c9 I( (' ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER /EXPIRATION DATE FAX NUMBER
1 -3' - Q a ` °Q
s-- B L / 3c / 04"( ( ) -
g .1 L CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE
E 8 i _e. tP1fic ic-‘ /0 is /66
APPLICANT COMPANY
f NAME n l APPLICANT NAME OFFICE PHONE
MAILING 1 c ADDRESS CITY,
1-VC'I1b✓\( \L, CITY,ST ,ZIPci[Li.-— Ct'15ELL ) 9`) ' - aa.5'O
42707 76Air— Tc rnA. W A 411'01 ( 1 -
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect 0 Tenant 0 Agent 0 Other(Describe) (625S) t(r';-‘9,.. - (r i S U
CONTACT NAL/15,,_, PRIMARY PHONE E-MAIL ADDRESS
S,` \I", ..._C._Z-4,-- (tIs3) �atP - :,42 T,
10 kip) P� 10{-AI(rt , C..1..
LENDER Per RCW 19.27.095: Lender information is NAME
required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ <nT1(1. 00
SPRINKLERED BUILDING? 5 YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES 0 NO
WATER SERVICE PROVIDER o LAKEHAVEN o HIGHLINE C TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER ü LAKEHAVEN 0 HIGHLINE ❑ PRIVATE(SEPTIC)
• •
• PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ. FT. SQ. FT. SQ. FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS(DESCRIB
DECK(COVERED?)
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL 7" TOTAL EXISTING SF TOTAL PROPOSED SF TOTAL SF
NUMBER OF FLOORS
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be ins ; led. relocated 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(Commercial) WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS(or ./Shower combo) SHOWERS WATER CLOSETS(Tojlery MISC(Describe)
DISHWASHE' SINKS _ DRINKING FOUNTAINS
GAS PIPE e TLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sink.( 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.
NAME/TITLE r �;, inc11.1. DATE ///L(/�gnature) (Title)
RELATIONSHIP TO PROJECT 0 Owner ❑ Agent Contractor 0 Architect 0 Other
FOR OFFICE USE ONLY
o NEW o ADDITION ❑ALTERATION ❑ REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑YES ❑NO BASIC PLAN? o YES ❑NO
ZONING DESIGNATION CHANGE OF USE? o YES ❑NO
NEW ADDRESS REQUIRED? ❑YES ❑NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? o YES ❑NO DEMO PERMIT REQUIRED? ❑YES ❑NO
Bulletin#100—August 19,2004 I'ge 2 of 4 k\Handouts\Permit Application