05-104844 � • �
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Federa�way P -�+ R�/II"� :
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� PEDBRAL WAY,WA 98063-971t
T59-d35-2607•FAX�53d35• / /
,,,u,�,.R��7��,nr�„ay.��!TY OF FEDERAL WA �
B�,ll�,�iNG DEPT. I
The oilowi is uired in ormatlon-an i p tete Zicatton wtil rtot be acce ted, piease rtnt ie {bi i n o r
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� SITE ADDRFSS l� c ['. Ci, , ,� � /j�.3 S� ' _��;`�' � �r� - � SUITE/UNiIT 1� I 1
� ASSESSOR'3 TAX/pARCEL• �I s 13 �
� — — — — — — LOT SIZE(s�
LEGAL DFSCRIPTION(e.g.Acme Estates,Lot 1 J
"°d"ep°I"te auaslar le�ge�llr+�Dd deaca+rtlonl
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� TYPE OF PERMIT ❑BIIII.DING ❑ PLUMBING ❑ MECHANICAI, -
` � ❑ DEMOLITION C] ELECTRICAL ❑ EPiGINEERING�@ FIRE PREVENTION SYSTEM
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� PRO DFSC O (Pro►'�de detai(ed cription of work� ed on ermit nl
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PROJECT NAME(Name of Business or Owner Last N � ��.i'�C �',, r�S '
• ' • - �
PROPERTY NAME. �
PRIMARY PHONE
OWNER �S C. � �\f����'/��'�" I� (�f'�` �(-? ��� J Cj �� {i���'
MAfLIN6 ADDRESS ATE P
f 1 �5�� .�.1 �,, o :. �, �,� � ��cc�� `' 7 L�:%S
CONTRACTOR �Mp�NAMB APPL[CANT NAME OFF[CE PHONE
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MAfuNd ADD CPIY, ATE,TdP CEI.L PHONE
5' e, �_ ' , C�%, r . �[,. �r� � � _ -
C17Y OF FEDBRAL WAY BUSlNESS UC�NSE NUMBER, &XPIRATION DATE FAX N(1MBSR
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CONTRAC7'OR5 ISTRATION NUMBER(copy ot eard reqn�ced with eaoh applic=tioa EXpIRAT10N DATE
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APPLICANT � � NY NAME APPUGN'C NAME
OFFICE PHONE
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MAIUNO ADDRESS ClTY,STATE,ZIP " CELL PHONE
RELATIONSHIP TO PRWECT FAX NUMBER
❑Architect o Tenant ❑Agent ❑Other(Describe) � � _
CONTACT E PwAURlr PttONE UbtAtLADDREss
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LENDER �E
IdAIL[NO AbDR6S3 dTY.8TATB,ZIP
1 � : 1 � • ' •
EXISTING USE � PROPOSED USE � 1 � L% �
EXISTING A3SESSED/APPRAISED VALUE �� s �_ VALUE OF PROPOSED WORK $ �, L.J r�
SPRINKLERED BLTILDING? �YES ❑NO FIRE SIIPPRFSSION SY3TEM PROp03ED/ItF,QUIRED? �YES o NO
WATER SERVICE PROVIDER.•.O LAKEEiAVEN � ffiQrHLINE O TACOMA O PRIVATE(WELL) "
SEW,�R SERVICE PROVIDER ❑ LAKEHAVEN p ffiGE�INE ❑PRIVATE SEPTIC)
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AREA DESCRIPTION F.XI3TING PROPOSED TOTAL
s .�r. s .�r. s .�r.
BASEMENT
FIRST .
SECOND
THIRD �
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FOURTH ,. ' '
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ADDITIONAL FLOORS(D RIBE) �
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DECK(COVERED?) I
GARAG� O CARPORT❑ ,:' ;
wsrnra ra so mr�u. ; _. ' _.._.____....�
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NUMBER OF FLOORS .� "t'�� � �
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••NEWHOMES ONLY" NUMBER OF BEDROOMS ESTIMATEU SELLING PRICE $ �
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Indicate number of each type of furlure to 6e installed or relocateai as of this project. Do not include existing fvetures to remain.
MECIiAlVICAL �,
Value of Mechanical Work $ ••.�
A[R HANDLIN(3 UNITS EVAPORATIVE COOLERS <}A3 G'S� REFRI(1.SYSTEMS
BBQS FANS HOODS�comme\.eAq, WOODSTOVES
BOILERS �.,.., FIREPI.ACE INSER1'S RAN(}ES ' �'`� M[SC(Describe)
• COMPRE330R3 F'URNACES QAS WATEIt HEATEK� \
DUC1'3 QA9 PIPE OUTLET3 �
PLilMSING �
BATHTUB3�a� sn�co� SHOWERS WATER CL03ET3 Roned MIS escribe)
DISHWAS�2S SINKS DRINHINQ FOUNTAINS
(}A,,,S-Pf�'E OUTLETS SUMPS RAINWATER SYST
WA3HINd MACHINES U AL3 HOSE BIBBS
LAVS�e„m„em VA M BREAKERS ELECTRIC WATER HEATERS
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!ce�t{f'y unde�penalty oj per,/ury that the Hon furnlshed by me is tnee and correct to!he 6est of my knoui(edgq and,(trrther,that I
am aathoriaed by the oruner oj the abovs premise !o perform the ruork jor urhich ths permit appitcallon is made. !further agree to hold
harmiess the Cily of Federa(Way as to any clabn/tncluding costs� expenses, and attorneyt'fees tncurred!n the investtgallon and dsjense oj
such ciaim/,which may made by any peraon,inciuding the underatgne�and fiied agatnst the City ojFsderal Way,but on/y where such claim
arises out of the reltan f the c1ly,including ffice and employess,upon the accuracy of the i►{(ormallon sapplied to the ctty as a par!oj
this appifcatton. �
NAME/TITLE Cq,�,� DATE �f� C��
(Signa (7YUe)
RELATIONSHIP TO PROJEC ❑ O er ❑Agent ❑ Contractor ❑Architect o Other
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Butleun#100—Januar�,7,2005 . Pago 2 of 4 k�Handouts�Pemut Apptieation