06-105262. EIVED
pf 7
nrr of j / Federal Way �c o�� PERMIT tF OME
SF MF EL PL DE EN FP
s5s2ssn�avenn�esouriF•Pa�j sit$]# 1-Ei3ERAl P`�
FF.D =WAY, wA 98D& , 1a 13U1LD)NG DE;APPLICATION
253.835-2807• FAX 253.M.2609
u+anfr. Yfu�[�fer�iiwntr.runl
The vlittwin is etir9ed i vrmation - an incvrr: fete a licativr7 will not be accei2ted. Please Print le ibl an in ortype
�/ PROPERTY
CC�
SITE ADDRESS 4 D �' 14f►' SUITE/UNIT # 1
ASSESSOR'S TAX/PARCEL # �� ?= i] - 3 LOT SIZE (sf Z'T +05-b
LEGAL DESCRIPTION (e.g. Acme Estates, Lot I)
(Affnch separate page for lengthy legal description)
PROJECT• •
TYPE OF PERMIT Ja BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description of work included on this permit only)
f7I4MD>Tif- FD6 p " , 1' ,(p �j L01' �-I b<WN(, 16TO AM'NUb OUTH
PROJECT NAME (Name of Business or Owner Last Name) P r�
PEOPLE•• •
PROPERTY
OWNER
[flow" zmelfe"
APPLICANT
NAME PRIMARY PHONE
Fgvut Mk"r~r kl t W-'r-
MAILING ADDRESS CITY, STATE, ZIP
4144-1k CONCI Te-U(1100 Lb, INC.
Nve RKAct4� L T7-
(42�) 48-7 -
5uo
MAILING ADDRESS
MOOD , IU�Tu Me • Wr1 ;
CITY, STATE, ZIP
Wocolt4VIU",- ,
CELL PHONE
(Uv )
CITY OFFEDERAL WAY BUSINESS LICENSE NUMBER
EXPIRATION DATE
FAX NUMBER
V - 6 5 - 1 0 'I- -k 7, v -
12,1 3 1 / Uba
(1J-2-t�)
_2 B
L
CONTRACTOR'S REGISTRATION NUMBER (copy of card required with each appHcationj
EXPIRATION DATE
COMPANY NAME APPLICANT NAME OFFICE PHONE
MAILING ADDRESS CnY, STATE, ZIP CELL PHONE
-2-101✓ pb< "(, &V],�. !�UITL 3 0 D 7)I%UMP, Whr 4IS402- ( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
Architect ❑ Tenant ❑ Agent ❑ Other (Describe) ( 2� )
CONTACT NAME PRIMARY PHONE �E-MAILADDRLSS
(.kWJWN CC- US7b rl (253 ) Z - 2i 6 % UtDMICIN e-& -09 I taH Cp
LENDER
Per RCW 19.27.095: Lender Warmation is NAME
required (f project value exceeds $5,000
MAILING ADDRESS CITY, STATE, ZIP PHONE
EXISTING USE NDNC,;
EXISTING ASSESSED/APPRAISED VALUE $
PROPOSED USE PVMPe>W� C'" Ca,OsU1�p-
VALUE OF PROPOSED WORK $ 1 L i D D U
SPRINKLERED BUILDING? ❑ YES j% NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES NO
WATER SERVICE PROVIDER ]d LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL) m
SEWER SERVICE PROVIDER yd LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC) �v-` (
PROJECT FLOOR AREAS
AREA DESCRIPTION
EXISTING
S . FT.
PROPOSED
S . FT.
TOTAL
S . FT.
BASEMENT
FIRST
O
��
SECUND
THIRD
FOURTH
ADDITIONAL FLOORS (DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT ❑
NUMBER OF FLOORS
EXISTING
PROPOSED
TOTAL.
TOTAL EXISTOO ST
TOTAL PROPOSED OF
TRr+i.
7
**NEW HOMES ONLY** NUMBER OF BEDROOMS ESTIMATED SELLING PRICE
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fmtures to remain.
Value of Mechanical Work
AIR HANDLING UNITS
BBQS
BOILERS
COMPRESSORS
DUCTS
PLUMBING
BATHTUBS (or7ub/Shower Combo)
DISHWASHERS
GAS PIPE OUTLETS
WASHING MACHINES
LAVS {nailm"7i Sln"i
COOLERS
FURNACES
GAS PIPE O
SINKS
SUMPS
URINALS
VACUUM BREAKERS
GAS LOGS
HOODS Ice
WATER HEATERS
WATER CLOSETS (Toilet)
DRINKING FOUNTAINS
'RALWAI'ER SYST
HOSE BIBBS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
WOODSTOVES
MISC (Describe)
MISC (Describe)
I certVy under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge, and further, that I
am authorized by the owner of the above premises to perform the work for which the permit application is made. I further agree to hold
hamless the City of Federal Way as to any claim (including costs, expenses. and attorneys' fees incurred in the investigation and defense of
such claim), which may be made by any person, including the undersigned, and filed against the City of Federal Way. but only where such claim
ar+--? pput of the reliance of 't city, includ'ng its officers and employees, upon the accuracy of the information supplied to the city as a part of
this application.
NAME/TITLE
LFIR
(Signature) : % (Mile)
RELATIONSHIP TO PROJECT ❑ Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
1 Q • 13 . 'A' 'Db -
FOR OFFICE USE ONLY
❑ NEW o ADDITION
❑ ALTERATION
❑ REPAIR ❑ TENANT IDR]PROVEMENT
BUILDING SHELL ONLY?
❑ YES ❑ NO
BASIC PLAN? ❑ YES
❑ NO
ZONING DESIGNATION
CHANGE OF USE? ❑ YES
❑ NO
NEW ADDRESS REQUIRED?
❑ YES ❑ NO
UP/SEPA/SU? ❑ YES
❑ NO
PLATTED LOT?
❑ YES ❑ NO
DEMO PERMIT REQUIRED? o YES
❑ NO
Bulletin #100 —January 1, 2006 Page 2 of 4 k\Handouts\Pennit Application