07-100799 ciiroP 4 RECEI V L. 07 " ''0 0 1 f
Federal Way PERMIT
cOMMjIN',x0E.ELOFME;T5Lni'ces -APPLICATION
�F MF CO ME EL PL DE EN.
33325 8',•A VENUE SOUTH•PO PDX 253-B3_T WAY,
FAX 9803-97/8 r1� 1 3 20 APPLI CATI O N
FEDERAL WAY,WA 98063-97]8 TD �_
rtm,u;.cir,/n((edrrnlwny�i)lgy OFDD�ENNOERALTTWAY
/ — , -
The following is requtred(in orrmatiOn-an incomplete application will not be accepted. Please print legibly(in ink)or type.
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- TS PROPERTY INFORMATION . . -
SITE ADDRESS 3 L/ '7 16 1 /4' 1 - S: Fee/672 q/ t j, , / SUITE/UNIT#
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ASSESSOR'S TAX/PARCEL# -- I 7 i C 1/4-1 - i_ 7 k' LOT SIZE (sf
LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1)
(Attach separate page for lengthy legal descnp ion)
■ PROJECT INFORMATION
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
❑ DEMOLITION 0 ELECTRICAL 0 ENGINEERING FIRE PREVENTION SYSTEM
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PROJECT DESCRIPTION(Provide detailed description of work included on this permit milli)
.te 'l / ►v, &2 - . `( Il i _ g/,
PROJECT NAME(Name of Business or Owner Last Name) kC)Lt.,td t91k 4,4 ,
• U PEOPLE INFORMATION
PROPERTY NAME
��Mti �n�1 PRIMARYpPHONE
OWNER leedGA...e/ N4• 44-ake/ ! �AtC'lltTf . ZL (U av ) f;63---/`fYJ
MAILING ADDRESS /� - CITY,STATE,ZIP E-MAIL ADDRESS
7o0 Aetjea 21 BE 4,,.f`tl er/i ted
CONTRACTOR COMPANY NAME A CANT NAME OFFICE PHONE
6„eGN R,4/ Coved e•249,/�pp<uvi, - ( )c"v -4',5-6��
MAILING ADDRESS /�y 7'1 Cl/ (i( `�(H- (EE7LyL�r.,P/�H) r.7 pnO-t5
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER C EXPIRATION..�� DATES FAX NUMBER
1lA
3.
COPY of card required I >
CON TRACTOR'S REGISTRATION Zz 9 6R w Q L Ec:)- 1 DATE E-MAILADDRESSale/4
with each application G` Q F^tti y� c. (� / "i 7 q/_O� D�4C `le
674"-
APPLICANT COMPANY J\NA f/r ,`f (y, APPLICANT NAME ` N
=y� /' OFFICE PHONE
MAILING ADDR SS
V ( C> , y�.. - ( -
CELL PHONE
RELATIONSHIP TO PROJECT FAX NUMB ER
0 Architect 0 Tenant 0 Agent ❑ Other ( ) _
PROJECT NAME J'._' PRIMARY PHONE E-MAIL ADDRESS
CONTACT N( L' L e/4 L4i— (*25j') LI 6f 7 S- 2'c'
LENDER NAME ! - Per RCW 19,27.095: .
Lender information is required if project value exceeds$5,000
MAILING ADDRESS CITY,STATE,ZIP PHONE
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. ` ,' -•.,: `. �:.,l :..III.-DETAILED.BUILDING INFORMATION.:::
EXISTING USE PROPOSED USE QCsf4..&4 2 f
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ 3 G a s-
SPRINKLERED BUILDING? YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? 0 YES 0 NO
WATER SERVICE PROVIDER prLAKEHAVEN ❑ HIGHLINE 0 TACOMA o PRIVATE(WELL)
SEWER SERVICE PROVIDER jikLAKEHAVEN 0 HIGHLINE 0 PRIVATE(SEPTIC)
pR•J • • 1.1
AREA DESC' •N .�� EXISTIN� ROPOSED •
•.m,.: TOTAL
SQ.FT. SQ. FT. .j. "T.
BAStivi✓NT
FIRST
SECOND
THIRD
ADDITIONAL FLOORS(DESCRIBE)
DECK(❑ COVERED OR O UNCOVERED?)
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL TOTAL EXISTING SI TOTAL PROPOSED Sr TOTAL Sr
NUMBER OF FLOORS
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type offixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $ (A COPY OF BID OR ESTIMATE MUST BE INCLUDED WITH APPLICATION)
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS PIPE OUTLETS WOODSTOVES
BBQS FANS GAS WATER HEATERS MISC(Describe)
BOILERS FIREPLACE INSERTS HOODS(Commercial)
COMPRESSORS FURNACES RANGES
DUCTS, ... :: GAS LOG SETS REFRIG. SYSTEMS
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PLUMBING
BATHTUBS(or Tub/Shower Combo) LAVS(Bathroom Sink:) URINALS MISC(Describe)
DISHWASHERS RAINWATER SYST VACUUM BREAKERS
DRINKING FOUNTAINS SHOWERS WATER CLOSETS(Toilet)
ELECTRIC WATER HEATERS SINKS WASHING MACHINES
HOSE BIBBS SUMPS
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SIGNATURE
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), whic, ay be made by any person,including the undersigned, and filed against the City of Federal Way,but only where such claim
arises out of e reli• ce of the city, including its officers and employees, upon the accuracy of the information supplied to the city as a part of
this applicat .n.
NAME/TITLE �,[////�� DATE C� -73 7..7
( aWre)��di'�'7^�'�" ' (Title)
RELATION IP TO PRO CT O Owner 0 Agent Contractor ❑ Architect 0 Other
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WPM
❑NEW a ADDITION a ALTERATION o REPAIR a TENANT IMPROVEMENT
BUILDING SHELL ONLY? a YES a NO BASIC PLAN? a YES a NO
ZONING DESIGNATION CHANGE OF USE? a YES o NO
NEW ADDRESS REQUIRED? o YES o NO UP/SEPA/SU? o YES o NO
PLATTED LOT? o YES o NO DEMO PERMIT REQUIRED? a YES a NO
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Bulletin#100—January 1,2007 Page 2 of 4 k\Handouts\Permit Application