06-101861 ' ' , .
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ITYOF�
Federa�wa����v�� pERMIT
COMMUNITYDEVEIAPMENT SF MF CO ME EL PL DE EN FP
333258THAVENUESOUfN.POBOX9,�8 APPLICATIQN �
FEDERAL WAY.WA 98063-9718
253-835-2607•FAX 253-835��� � � �0 Q�
�cu;u�.�i(uolledernlwaitc
The ollowi ' re ired i ormation-an incom lete a lication will not be acce ted: Please rint le ibi (in ink)or
. � . � . �
SITE ADDRESS ��2�1 a'�-�FI L �I C�ik1�J/�y JO.�Tk�- SUITE/UNIT#
ASSESSOR'S TAX/PARCEL# O � � � O 4 - ` � � � LOT SIZE(s�
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 11
lAttach sepmat page for lengthy legal descrlptbN
' • • ' •
TYPE OF PERMIT ❑ BUII,DING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING 8 FIRE PREVENTION SYSTEM
PROJECT D CRIPTION(Prouide detailed description of work included on this permit onlu)
A�� ,� �rG4-OCATE PfN���-�s Fo+� NE,� c,�a�.�.S — 3g roTA�
PROJECT NAME(Name of Business or Owner Last Name) T7 — 11\iRR.T
• • • • •
PROPERTY NAME /` PRiMARY PHONE
OWNER K1MC.C7 ��A'L-��I Wt��02ATlt�� ( ) -
MAiLiNG ADDRESS CI'fY.ST�1TE.ZIP
�,3 �, N�„� �-r�F �a Ro'ioo � (�YD£�AR.IL (� i�a42
CONTRACTOR COMPANY NAME APPLICANC NAME OFFICE PHONE
�iP-�SPR�+��es � c. Ky..� (�►2R.o�..� (2s3)Sz� -0099
�� MAILING ADDRESS CI'IY,STATE,ZIP CELL PHONE
o�¢ No�-a� S� 5��,�►r� �� 9s sg� � � _
CITY OF FEDERAI.WAY BUSINESS LICENSE NUMBER EXPIRAT[ON DATE FAX NUMBER
o `5 - t b o 4 3 ?i- / / (Zs3 ) 8ic. - log3
� 2-_ s L
CON1'RACTOR'S REGISTRA170N NUMBER(copy of cazd required with each appllcation) EXPIRA170N DA'IE
� � (� � 5 � �: � $ � Rs i2 � �ar�
APPLICANT COMPANY NAM APPLICANT NAME OFFICE PHONE
� ) -
MAILING CI1Y,STATE,ZIP CELL PHONE
� � ( l -
RELATIONSHIP TO PROJECT FAX NUMBER
❑ Architect ❑ Tenant ❑Agent ❑ Other(Descrtbe) ( ) -
CONTACT NAME PRIMARYPHONE E-MAILADDRESS
y� '�E1-�o�✓ (ZS 3� ��u. _ o o S 7
LENDER Per R�2$.27.098r Le�ader,i%}�'urmtttinn is NnHtE
t+r+e.�u4rer�{J';pr4jlect vatr,u�Ea�c�eds'$�'y000
MAILING ADDRESS C11Y,STATE,ZIP PHONE
� � -
1 1 : 1 • ' •
EXISTING USE I Y`�IC-Lf4'!J Q"l�-� PROPOSED USE �M�
�
EXISTING ASSESSED/APPRAI3ED VALUE $ VALUE OF PROPOSED WORK $ �T�SO C7
SPRINKLERED BUII.DING? �YES o NO FIRE 3UPPRESSION SYSTEM PROPOSED/RE$UIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER �HAVEN ❑ ffiGHLINE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER LAKEHAVEN ❑ ffiGHLINE ❑ PRIVATE(SEPTIC)
- . � .
�. o,.
• . •• •
AREA DESCRIPTION EXISTIIVG PROPOSED TOTAL
S .FT. S .FT. S .FT.
BASEMENT
FIRST
SECOND
'I'HIRD
FOURTH
ADDITIONAL FIAORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
NUMBER OF FIAORS �°'`c PROPoBBD rarn�. �ror,wawex�osr rorec.€xoroesose rorwas
'•NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be installed or reiocated as part of this project. Do not include existing fix[ures to remain.
11lECHANI('.AL
Value of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBgS FANS HOODS�commerc��) WOODSTOVES
BOILERS F[REPLACE INSERT'S RANGES MISC(Describe)
COMPRESSORS FURNACES GA.S WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATH'C[JBS�or�b/showercombol SHOWERS WAT'ER CIASEI'S rroueq MISC(Descdbe)
DISHWASHERS SINKS DRINHING FOUNfAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS(Bathroom Sinka) VACUUM BREAKERS ELECTRIC WATER HEATERS
1 •
1 certiJy under pena(ty oJ perjury that the ir4jormation furnished 6y me is true and correct to the best of my knowledge,and jurther,that I
am authorized bg the owner of the aboue premises to perform the work Jor which the permit application is made. I Jurther agree to hold
harmless the City oJ Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in the investigation and defense oj
such c(air�,�uhich may be made by any person,including the undersigned,and filed against the City of Federal Way,but only where such claim
arises out oJ the reliance of the city,including its o,��'iicers and employees,upon the accuracy of the ir{formation supp(ied to the city as a part of
this application.
NAME/TITLE ���� DATE � �Z' �4
(Signalure) � (T7Ue)
RELATIONSHIP PROJECT o Owner O Agent �]'Contractor O Architect ❑ Other
Fffr�i,�d�+'P'IG�LTS��.?1�FI.F �'.,
�,,,.
o NEW ❑ADDITI(3N a ALT�RATTOPT o llt�PAiR o'TENIlNT IM1'R(}V�MFNT
BUILDTNG:SHELL C?NLY? ❑Y'�S' ❑NO BA�YC PLAIY? ' o YES o 1�i0
ZONYNG IfESTGNATi�1V CHANGE 8F USE? o YES' o NO
1�W ADDRESS REQIIIREII? q 1fE8 [i Nf? UP/SEPA/SU? C1 YES'' n NO
PLATTED Y:t)'!'? o'YES o NO DEMO PEI�MIT RE�tI�RED? ❑'�tES o NO
Bulletin#100—January 7,2005 Page 2 of 4 k�I-Iandouts�Pernvt Application