05-104940 ' � �EG�/EC� �
cli9of�. � � ' � r_
Federal Way SEP 2 6 2005 �� - �� ��� D
COA(MUM7YDBVEfAP�M'SERVICBS P��M Y T SF MF CO ME EL PL DE EN P
333?58TMAVSNU8S0(JTfl.ro�, ��.LI CATI O N
FBDERAL WAY,WA 9QOG7•9718��Y OF F E p p
ass-aas-seo�•FAX 753-635-2609 B U I L D I NG /
� uvv ctlyofJ"Cd:.m.h�av mm� � V� �
Tiee oilowt is ufred in ormatiort-an{nco lete a licallon wtll not 6e acce d. Please rint 1e ibi ;n a
'� • � • - •
, SITE ADDRESS �C-I t SUITE/UMT I� _ ` .
ASSESSOR'S TAX/PARCEL# � _ � �� - � � („ LOT SIZE(s,�
-.,f..�
LEGAL DESCRIPTION(e.g.Aprte Estates,Lof 1 J
(�nacn+epa.ara paye fo.knptlw ka��ee+otpotml
I
., • . ,
TYPE OF PERMIT ❑BUILDING ❑ PLUIVIBING ❑ MECHANICAI, -
�
� � ❑ DEMOLITION ❑ ELECTRICAL ❑ EPiGINEERING FIRE PREVENTION SYSTEM
PROJECT,D CRIPTION(Pro ' e detailed descnption of wbr ' ded on t ' e tit
4 � • .
,
, .,.
,
r PROJECT NAME(Name of Business or Owner Last Name) ����(1 T�� �� x , � I -
�
• • • - •
` PROPERTY NAME .
PRIMARY PHONE
OwxER " � � _
�'
MAIUNGADDRESS CITY, ATE,
` — I oc
CONTRACTOR COMPANY AME /'v C/f.�. AP CAN?NAME CE PHONE
I � � -
� � R� CELLPHONE
A , p
� . : D � � � --� d � c� �
1 CITY O FEDE Y BU WC�NSE ER_ �+TIO�N/�"TE .- FAX NUMBER _
` — — s� L `��J `��7"�(�/ � 1
' CONTRAC7'OR REQISTRATION NUMBER(aop�ot card reqnired vlth eaeh applle�uo� E}(p�RAT(ON DATE
i
� — — — — — — — — — — — — � �
APPLICANT COMPA AME APPLICANT NAME OFFICE PHONE
! 3 � ) _
MAILlN(}ADDRESS C[TY,3TATE,Z[P ' CELL PHONE
1t RELATIONSHIP TO PRWECf FAX NUM�ER
r ❑ Architect ❑Tenant O Agent ❑ Other(Describe
/ ( � -
CONTACT NAME PRIMARYpHONE E-MAILADDRE33
, �S 3 C�- $�r3o � �
LENDER �E
MAIWNO ADDRESS ClTY,ST
�
� � : 1 � • • •
ERISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED YALUE � VALUE OF PROPOSED WORK 7�
SPRINKLERFD BLTILDING? ❑YES p NO FIRE SIIPPRESSION SYSTEM PROPOSED/RF,QUIREDP ❑YES ❑ NO
WATER SERVICE PROVIDER p LAI{EIiAVEN p ffiGgi,INE p TACpMA O PRIVATE(WELL)
SEWFR BERVICE PROVIDER p yAKEEiAVEN p HIGIiLINE p pgIVATE SEPTIC
-• • • -
AREA DESCRIPTION ERISTING PROPOSED TOTAL
S .FT. S .FT. S .FT.
BASEMENT
FIRST -
SECOND
THIRD
FOiJRTH .
ADDITIONAL FLOORS(DES BE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FLOORS suarna aaoroaw toru. ; ._.. -R......__..�� _....,_� ..
,
•�NEW HOMES ONLY'• NUMBER OF BEDROOMS ESTIMATED S NQ�PRICE $ �
� I
Indicate number of each type of fur[ure to 6e insta!!ed or relocated art of this project. Do n.ot inc(ude existing fueiures to rem.ain. '
IKECFIAHICe4L `\
Vatue of Mechanica(Work $
\
AIR HANDLINd UNITS EVAPO E COOLERS C}A3 LOOS REFRIG.SYSTEMS
BBQS FAN HOOD3�cem�,d.q WOODSTOVES '
BOILERS PI.ACE INSERT'S RANQES � MI$C(Deacribe) i
• COMPRE330RS FURNACES GAS WATE1t HEATER4
DUCTS QA9 PIPE OUTLET3
PLUMSING
BATHTUB3(or7tib/sh mu� 3HOWER3 WATER CLOSEI`S Rotkq MISC(Deacribe) �
DISHWASHERS SINKS DRINK[Nd FOUNTAINS +
(}AS PIPE O SUMP3 RAINWATER 3YST
WASH[N ACHINES URINALS HOSE B[BBS �
I.AV e.eveomatn� VACUUM BREAKERS ELECTRIC WATER HEATERS
� • �
�I cert�y underp�nalty of perJury that the t�{tormaHon ferntahed by me is true and correct to the 6est ojmy knouiiadgq and further,that I �
am authorised by the owner oj the above premises to perform the work jor which ihs permt!appitcatlon is mads. I further agrse to hold
havmiess the City oj Federal Way as to any ctafm(tncluding costa, �xpenses, and attorneya'jses lncurrsd tn the InvesNga![on and dejense oj I
such etatmJ,which may 6e by any person,inc(uding the understgned,and filed agatnst the Clty oj Federae(Way,but onig where such claim
artses out ojlhe rcliancs'"ojtf ity,incii flr.�and empyioyees�upon ths accuracy of!he tr{formallon auppLtad to the ctly as a part oj j
this appl�cation. / \ �l 1
i
E �
� NAME/TITLE�� ��� � � �� ��✓<�U/�O�IG� DATE "/ � �� 1
� �
� ( 1Bnature) f�'Wq i
RELA�'IONSHIP ROJECT ❑ Owner ❑Agent ❑ Contractor ❑Architect ❑ Other �
,
i
�
�
1
BulloUn#100—Janua�y 7�2pp5 . Page 2 of 4 k�Handouts�Permit App(ication