04-103068 COMAIUNI7Y DEL'ELOPNE�IT SERVICES
��'�� � 33�30 FIRST VVAY SOUTH-PO BOX 971 B
r FEDERAL W.4Y,WA 9E�63-9718
F��a��ay�� �'�,t�MIT APPLICA�'IO1� � z53-66I4I15•FAX 253-661-4129
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eo�om�e use o�iY: FW File Number: Q � - a � l3 - � � / /
The followin is �����PnTation-an incom lete a lication will not be acce ted. Please rint le ibl (in ink)arr t e.
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SITE ADDRESS: L3q��c� L�dY�C M_�� 5�.� SUITE/APT#
ASSESSOR'S TAX/PARCEL#: � C) �� O � - � � 3 � SQUARE FOOTAGE OF LOT:
LEGAL DESCRIPTION (e.g.:Acme Esrates, Lot I) �� y(a~tt��J
(Attach separate page for lengthy legal description)
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TYPE OF PERMIT(This application): ?BUILDING ? PLUMBING ? MECHANICAL ? DEMOLTTION
? ELECTRICAL ? ENGINEERING . FIRE PREVENTION SYSTEM�
PROJECT DESCRIPTION (Provide detailed description of work included on this oermit onlv): r F�►ST'I�L.L � �� 4—L�iL
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PROJECT NAME (Name of Business/Owner Last Name): �1�������,� ��t��/-�� ��/-lT��_
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PROPERTY NAME: PRIMARY PFiONE
,_'� OWNER: I f�� '� �� �.R-��iZM�i- C:.rc�r�� t�- (63���j3� - �3��'j
MAILING ADDRES (STREET ADDRESS;): CITY,STATE,Z[P
, � �SCa k al..�,A�� S`r ; �A,.�, �SZ. ���Z�Z
CONTRACTOR: NAME COMPANY OFF[CE PHONE:
m�� �a�s�..�a ��,.,�� �'������r�,� �Azs�� ��,�3 -s� -z�.
MA[L[NG ADDRESS(STREET ADDRESS;): CITY,STATE,ZIP CELL PHONE:
(�^ �- 1543 ��r-Dr�-i�ti�t� ,A:19�iz (2�) ?3� -9k3Z_
CITY OF PEDERAL WAY BUSINE55 LICENSE NUMBER: EXPIRATION D E: FAX NUMBBR:
L`3.-8 L -� � c� � � �.-� e� ~ 6� tz� '3� ��.��Q c�z� )��3 -So'l�t
CONTRACTOR'S REGISTRATION NUMBER: EXPIRATION DATE:
(copy of card requlred with each appllcatlon)� ,� ��L � � � .� 1 q � �j �� /�� /�
LENDER: NAME: DAYI'IME PHpNE:
� pf Propased Value>55.000) � - ( �) � _
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MAILINC ADDRESS(STREET ADDRESS:): CITY,STATE,ZIP
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APPLICANT: NAME: COMPANY OFFICE PHONE:
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MAILING ADDRE�SS(STREET ADDRESS): CITY,STATE,ZIP EVENING PHONE:
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RELATIONSHIP TO PROJECT: FAX NUMBER:
�Architect � Tenant � Other(Describe): � ., `,� , -
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CONTACT PERSON FOR TI�IIS PROJECT: ?Property Owner "' ontracEo ?Applicant E�uL A°D�ess: '
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E�STING USE: PROPOSED USE: I''� ''w��LY�.�
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EXISTING ASSESSED/APPRAISED VALUE S VALUE OF PROPOSED WORK: S �,E��C�?.
/ SPRINKLERED BUII..DING? � Z NO FIItE SUPPRESSION SYSTEM PROPOSED/REQUIRED?: ?YES ?NO
WATER SERVICE PROVIDER: ?LAKEHAVEN ?HIGHLINE ?TACOMA ?PRNATE(WELL) -
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_ _SEWER SERVICE PROVIDER: ?LAKEHAVEN _.?HIGl-ILINE ?.PRNATE(SEPTIC)
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AREA DESCRIPTION EXISTING S . FT. PROPOSED S . FT. TOTAL
n BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED?)
GARAGE/CARPORT
HOW MANY FLOORS? Torn�EwsT�,c TOT.�L PROPOSED TOT�1L EXIISIINC AND PROPOSED
"NEW HOMES ONLY*' NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
Indicate number of each type of fixture that is to be ins[alled or relocated as part of this project. Do not include exis[ing fixtures to remain.
MECHANICAL
Value ofMechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG. SYSTEMS
BBQS FANS HOODS cc��,�me«�an WOODSTOVES
BOILERS FIREPLACE INSERTS RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
r ; PLUMBING
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� BATHTUBS�a�T„bisnowe�comeo� SHOWERS WATER CLOSETS Roue�� MISC(Describe)
DISHWASHERS SIIVKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYS
'WASHING MACHINES URINALS HOSE BIBBS '
LAVS�m�oom s+�k VACUUM BREAKERS ELECTRIC WATER HEATERS
I certify under penalty of perfury that the information furnished 6y 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 unders3gned,and
�led agalnst the City of F deral Way, b t o y where such claim arises out of the reltance of the city, tncluding its o�ce�s
and employees, upon tHe cc acy of in rmation supplied to the city as a part of this application.
NAME/TITLE: � 1 ` -�� DATE: �'�Z� • ZE`-C��
(Signature) � itle) � �
RELATIONSHIP TO PROJECT: � Property Owner � Applicant � ontractor � Architect �
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?NEW :t : � ?;ADDYTIQN , . , .
': ?ALTERATI4�N,... : ?:KEPAIR :� ° ?TEI�TANT I11�R0'VEMEIVT ..'; .. .:
�,., . BUII�p�IG SHELL U1VLY't ?YES '?AIO ', BRSIC PLE±►N? ?YES �;?,NO
�ONII�IGDFSIGNATiON:� "' .�HANGE OF USE? ?YES ?NO
� NEWw�DRESS RE(?t}IRED7 ; . ?;'YES _?IVO ` �I1P!$EPAISU? : ?YES .?NO
PLA'f'��U LOT7 ., �•i . � .i ?;;YES �?NO '�; � ' ." ' DEMO PERMIT REQUII2ED? ?YES ?NQ
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