05-104613 ' �. . � -
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Federal way P � -� ' \' ��.� �
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r G�OMbNM7YDBVfiLOPMEM'SBRVlCBS � �,ry
s�zs�"�e�,e�`.��"'" APPLICATI;��F U
FBDERAL WAY,WA 9d06J-971A p /
453-d35-2607•FAX T53-635-4609 .
�,�,�,a��ne-.d. .M.. /I Y �� EDERq �
�UILDINC,p�p
The oiiowt is re fred in ormation-an{ncc Tete iicallon cutii not be acce �d. Piease rtnt ie ibi in tn or
-• • • • •
' SITE ADDRESS G�'� �G SUITE/iJDTIT�
ASSESSOR'S TAX/PARCEL#` � � �,� � �- � � (A LpT SIZE(s,�
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� LEGAI.DESCRIPTION(e.g.Acm.e Esfates,Lot 1 J
` �Aandtsepa.atepcyefo.�ery�f�r kpo(descApU°nf
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TYPE OF PERMIT �;g� . -
DING ❑ PLUMBING ❑ MF.CHANICpI,
❑ DEMQ*[TION ❑ ELECTRICAL ❑ ENGINEERING IRE PREVENTION SYSTEM
� PROJECT DESCRIPTION(Provide detailed desrxiption of work ir►ctuded on this e it
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E PROJECT NAME(Name of Business or Owner Last Name) ` � �� -
� • • • - •
PROPERTY NAME
� PRIMARY PHONE
oWxEit ; � �� � � _
MAILINO AD RESS �i � � ,�ATE,Z[P
CONTRACTOR �Mp�N� � APP CANT AME OFF[CE PHONE
��� C� (�0617�-(a'd`�S��
MAILINa ADDRESS � CITY STATE,ZI CELL PHONE
C��::_. 9���� (; }
OF FED L Y USWESS WCENSE NUMBER EXPIRAT[ON DATE -= RAX NUMBER T
_ -.�Q ��� _-B L � � �a� �7,�7-a�d
CONTRA(.'fORS RE4[3TRATION NUMBER(copy o[eud reqnired wit4 eaeh applieation) EXPIRATION DATE
_ _ _ — � �
APPLICANT COMPA ME APPLICANT NAME OEFICE PHONE
MAILING R S CI7Y,STATE,ZIP ' CELL PHONE
� REWTIONSHIP TO PRWECf FAX NUM�ER
f o Architect ❑Tenant ❑Agent O Other(DescribeJ � � _
CONTACT NAME PRIMARYpHONE E-MAILADDRESS
� I�I� Zo(n � -Q 9 `f (� .
� LENDER �E
r MA[LINO ADDRESS C11Y,STATB,ZIP
I
� 1 • : 1 � • . . ,
� EXISTING USE PROPOSED USE
�
j EXISTING ASSESSED/APPRAISED VALUE �$ VALUE OF PROPOSED WORK �$ 1 , �O�
�� SPRINKLERED BiJILDING? ❑ YF.S p NO FIRE SIIPPRESSION SYSTEM PROPOSED/REQUIREDP ❑YES p NO
WATER SERVICE PROVIDER ❑LAKEHAVEN O HIG�INE ❑TACOMA ❑pRIVATE(WELL)
SEWER SERVICE PROVIDER p LAI�HAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
•. • • •
AREA DESCRIPTION ERISTING PROPOSED TOTAL
s .�r. s .�r. s .�r. ,
BASEMENT
FIRST - �
SECOND
THIRD
FOURTH • ,
ADDIT[ONAL FLOORS(DESCRIBE). '
DECK(COVERED?J �
GARAGE ❑ CARPORT❑ ,. I
NLTMBER OF FLOORS s�asrmo �eorosso �,,, ror,v, .� _ R��_—s�� ';it;s�� '
.�
44�W HOME�S O„LI � NUMBER OF BEDROOMS `�.. ESTIM STED SELLING PRICE $
l �
Indicate num6er of each type of fuKure to 6e instaQed relocated os p this project. Do n.ot include existing fiztures to remain. �
MEGFIAMCAL �
Value of Mechanical Work $ � \ �
AIR HANDLING UNITS �EVAPORATNE COOLERS dA3 LOGS REFRIG.SYSTEMS
BBQS � FANS HOOD3�ca�e,d,q WOODSTOVES �
BOILERS r •,..:.. FIREPLACE INSERTS RAN(}ES ' „.; MISC(Describe)
• COMPRES30RS i� FUI2NACE3 (}AS WATECt H�ATERS
DUCTS i (3A3 PIPE OUTLETS
PLUb�ING �';'
BATHTUB3(er�6/s6owercom� SHOWER3 WATER CLOSE.�'3(To�teq MI3C(Describe)
D[SHWASH�F�S SINKS DRINKINO FOUNTAINS
CiAS PIPbT'OUTLETS SUMPS RAINWATER SYST
WAS�O MACHINES URINALS HOSE BIBBS
S�9.tlwomstolw� VACUUM BREAKERS ELECTRIC Vf/ATER HEATERS
� •
I eertj�y under pena�ty of perfury that the i�jormatton furnished by ine is trtce and correct to the best of my knou�iedge,and further,that I
am authorised 6y the owner of the above prem{ses to perjorm the work jor whtch the permit appitcallon is made. I further agree to hotd
harmless the City of Federtic!Way as W any clatm({nciuding costs, expenses, and attorneys'fees incurred in the lnvestlgatlon and dejense oj
such claimJ,which may be rr�ade by any peraon,inc(udtrtg the understgned,and filed argacinst the Clty oj Federal Way,but only where such ciaim
arlses oat ojthe reitance of the ty inciuding its ojJicers and empioyess,upon the accuracy of t/ee t�{jormatlon aupp(ted to the clty as a part oj
this applicatlon.
NAME/TITLE DATE �—�G — O�
,,.•= ( atu (nue) �
RELATIONSHIP'T6�pR0 wner O Agent ❑ Contractor ❑ Architect ❑ Other y
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Bulletin#100—Januar�,�,2pp5 . Page 2 of 4 k�Handouts�I'ermit Application