06-105020CITY or 'A
Federal Way �F_i PERMIT
COMMUNITYDVE SOPMENT SERVICES c A` '. I CATI ON
33325 SMAVENUE SOU7II • PO BOX 9718 0
FEDERAL WAY, WA 9900-9718 O
253-835-2607• FAX 253-835-2609
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SITEADDRESS i ++ '(p t11 � ' ' ` �Tt'l'F/UNTT #
S _
ASSESSOR'S TAX/PARCEL # L 1 - � LOT SIZE (sj)
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
Mffwh separate pagela L aWft k9W de'BPmN
PROJECT• •
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING>( FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on
��fl-S7"d//d-Tie /.3-A l A-A)rIj/ / V,
PROJECT NAME (Name of Business or Owner Last Name)
PEOPLE•• •
PROPERTY
OWNER
CONTRACTOR
APPLICANT
CONTACT
LENDER
EXISTING USE
NAME PRIMARY PHONE
t"G -r,t v ( -
MAILING ADDRESS CITY, STATE, ZIP
Sa.3� 7#
COMPANY NAME
i2�� ,�f�
APPILCANr NAME
ST,�vr Sr/1crT. 2
OFFICE PHONE
voe) zFt/ -17Z
MAILING ADDRESS
30/ 3 3 R� U/_ Nb.
CITY, STATE, ZIP
$',647711S wA
CELL PHONE
(7yJ) itbZ
- 723 9
CITY OF FEDERAL WAY BUSINESS LICEN. . NUMBER EXPIRATION DATE
2 o-b❑--Z
FAX NUMBER
.... ,�-B L
C R'3 ISTF/ITION NUMBER (ooyy of eard required w" emb m"Heatton)
-1IsZ 1 Y0.0.5
EXPIRATION DATE
---I*r/ // /tr6
COMPANY NAME
CA yl y
APPLICANT NAME
OFFICE PHONE
( ) -
MAILING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
❑ Architect ❑ Tenant ❑ Agent ❑ Other (Describe)
FAX NUMBER
( ) -
NAMI: 5775v/1=. 5T/1�7/71I�i%� P(9" RY� HCJ�IoG - 72,5- k.-MAIL ADDR>;5S
Per RCW I9.27.095: Lender irLforntatim is
required (fprnject value exceeds $5,000
NAME
M1AA"G ADDRESS
CITY, STATE, ZIP
PHONE
EXISTING ASSESSED/APPRAISED VALUE $
PROPOSED USE
VALUE OF PROPOSED WORK
SPnINKT-FRED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? / YES
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
❑ NO
PROJECT FLOOR AREAS
AREA DESCRIPTION
EffiSTING
FT.
PROPOSED
SQ.FT.
TOTAL
S . FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
treorae®
�
� �
T&rsi-pRomauar
torALw
"NEW HOMES ONLY"* NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Ind(cale ruunher of vvjrl( type gJ_flL%1are to be installed or relocated as part of this project Do not include existing fixtures to remain.
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
BATHTUBS (or1)jb/Shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS (oou,mom �nk+l
EVAPORATIVE COOLERS
FANS
FIREPLACE INSERTS
FURNACES
GAS PIPE OUTLETS
SHOWERS
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS (commemi�)
RANGES
GAS WATER HEATERS
WATER CLOSETS rrouey _
DRINIIING FOUNTAINS
RAINWATER SYST
HOSE BtBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I ce"Vy under penalty of pedury that the igformation furnished by me is true and correct to the nest 4f my knowledge, and further, that I
am authorized by the owner of the oboue premises to perform the work for which the permit application is made. I.further agree to hold
harmless the City gf Federol Way as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation and dgfense of
such claim), which may be made by any person, Including the undersigned, andfiled against the City gfFederal Bray, but only inhere such claim
arises out of the reliance 4f the city, including its and employees, upon: the accuracy 4f the irlfor oration supplied to the city as a part of
this application. ,SO' / f/
NAME/TITLE
TO P�fk1ECT ❑ Owner ❑ Agent ACOntractor ❑ Architect ❑ Other .5Uld
FOR OFFICE USE ONLY
❑ NEW ❑ ADDITION
❑ ALTERATION
❑ REPAIR ❑ TENANT IMPROVEMENT
BUILDING SHELL ONLY? ❑ YES ❑ NO
BASIC PLAN? ❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE? ❑ YES
❑ NO
NEW ADDRESS REQMR)ED? ❑ YES ❑ NO
UP/SEPA/SU? ❑ YES
❑ NO
PLATTED LOT? ❑ YES ❑ NO
DEMO PERMIT REQUIRED? ❑ YES
❑ NO
Bulletin #100 —January 1, 2006 Page 2 of 4 k\llandouts\Permit Application