05-104997 l
, �". ����.C� y �
c�noF �� 'M�,� '_ �L � �
Federal W �-��-�
� � �
coMmruxrrrnEVEcorMENrsE�p� g z00�. PERMIT �� �� ��5C0 ME EL PL DE E FP
333258THAVENUES �eoX9�18 J A P P L I C A T I O N � wA�� �
FEDERAL WAY� 8
253-835-2607•FAX 25 6�Q��
iuwu,.dtuo�Tederaluia���l/ ��RA 4- E- �rGRA�
��G D �' �'�►}� ::;;�`� o� S.
The ollowin �pt ����LD��
j g is required infor'tnation-an incomplete a plication will not be"acce ted. Please print legibly(in ink)or
. � . � . �
SITE ADDRESS J I ��� �Z �W �� SUITE/iTNIT#
ASSESSOR'S TAX/PARCEL# O � � I ��- _ � �� LOT SIZE(s�
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
(Atiach sepornle poge for IengFhy Iegol descnptioN
' • • ' •
TYPE OF PERMIT �BUII.DING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING�FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Prouide detailed descripiion of work included on this permit onlu)
'��c Sc�r.�K�.��► i�� � � `" l�s�'oP C�Y��NG
,, / �- /1�Lj2,i l' F�-�v��//�!�`Ka�%�1�1�t�'—
_����� ��� /V�J ^
PROJECT NAME(Name of Business or Owner Last Name) ��'(�(X� ���{��
• � • • •
PROPERTY NAME PRIMARY PHONE
o�R rn�.,�.cF�Q �--�r�c�-E,�.� �,ac� _ 3q3
MAII,ING ADDRESS CT1Y TE,ZIP
�(� � )c Co�� S t�u�r, �� �j � �- Z� yS
CONTRACTOR r�MPANY NAMR �� p APPLICANT E OFFICE PHONE
�M.�C�S� '��'_t YZ>��}��M � ( ZS� �71 - S�S�''J
MAII,ING ADDRESS •i �,n ..ITY,STATE,ZIP CELL PHONE
l���l ���i.� vl1�,t�.s-�'�-EX SS� Gc Cc., � gc� ( ) -
CI1Y OF FEDERAL WAY BUSINESS ICENSE NUM ER IRATION ATE FAX NUMBER
- - - - - - - - - --sL � � �YzS�a`1� - �.Sd�
CON'IRAC1'OR'S REGISIRATION NUMBER(copy of card required with each applicatlon) EXPIRATfON DATE
WIOD�E�Pi �I��LP _ _ lZ�3i iOS_
APPLICANT COMPANY N APPLICANT NAME OFFICE PHONE
� � -
MAILING ADDRESS CITY,STATE,ZIP CELL PHONE
l � -
RELA170NSHIP TO PROJECT L{ / � FAX NUMBER
❑ Architect ❑Tenant ❑Agent ❑ Other(Desc�c� l-6`��•� ( ) -
CONTACT N ._ (�S j xo� ( - � rn/� E-�ntt npDa�ss i
�� o�t� �� ..�L / jV 10 b �r_ �v�2.
LENDER Per RCW 19.27.095: Lender information is �E
required�j'project ualue exceeds$5,000
..MAILING ADDfiESS CITY.STATE,ZIP PHONE
� � -
� 1 : 1 � I 1 • • •
EXISTING USE �6r�. �C/ � PROPOSED USE !G�/I/L�StL ��i�i�i�i�'1�'�(�-
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ �DO�^-
SPRINKLERED BUII.DING? E�'YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/RE$UIItED? �YE.S ❑ NO
WATER SERVICE PROVIDER ❑ LAHEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
�
c
• • •• •
AREA DESCRIPTION ERISTING PROPOSED TOTAL
S .FT. S .FT. .FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FIAORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FIAORS E81ST1''� pROP0.4SD TOTAL TOTAL R.n9TQ1f}gR roru,rAorosao sr ro:,,,,sr
*•NEW HOMES ONLY•* NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate numl�er o,f each type of fudure to be installed or relocated as part of this project Do not indude existing fixtures to rema6i.
MECF�AIVICAL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS IAGS REFRIG.SYSTEMS
BBQS FANS HOODS(commere�aD WOODSI'OVES
BOILERS FIREPLACE INSERT'S RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OLTILETS
PLUMBIlVG
BATHTUBS(or'hib/Shower Combo) SHOWERS WATER CIASEIS Croaeq MISC(Descdbe)
DISHWASHERS SINKS DRINHING FOUNCAINS
GAS PIPE OUTI,ETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathmom Sinks) VACWM BREAKERS ELECTRIC WATER HEATERS
� �
I cert4fy under penalty of perjury that the information furnished by me is true and oorrect to the best of my knou�ledge,and further, that I
am authorized 6y the owner oj the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the GSity of Federal Way as to any claim Cncluding cosks, e�rpenses, nnd attorneys'fees incurred in the investigation and dejense of
such clai�,u�hich may be made by any person,including the undersigned,and f led against the City of Federnl Way,but only where such claim
arises out of the reliance of the city,including its o„fjicers and employees,upon the accuracy oj the ir4formation supplied to the city as a part of
this application.
NAME�TITLE DATE 2i.� Q S—
(Signature) �peJ
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑Architect ��ther ����`'X'�, �
FOR OFFICE USE ONLY
❑NEW ❑ADDITION ❑ALTERATION ❑REPAIR - n TENANT IIVIPROVEMENT
BUII.DING SSELL ONLY? ❑YES ❑NO BASIC PLAN? ❑YE,S ❑NO
ZONIIVG DESIGNATION CHANGE OF USE? ❑YES ❑NO
NEW ADDRESS REgUIItED? ❑YES ❑NO UP/SEPA/SU? ❑YES ❑NO
PLATTED LOT? ❑YE,,S ❑NO DEMO PERNIIT RE$UIItED? ❑YE,S ❑NO
Bulletin#100—January 7,2005 Page 2 of 4 k�Handouts�Permit Application