06-103810 �EG�I� ..�.�
tin oF v� — � D� �� �
Federal Way 12oos pERMIT
COMMUMTY DEVEIAPMENT SERVICES
A�G �- SF MF CO ME EL PL DE EN FP
333258TMAVEMlESOUfH.�BOX9,�8 ��LICATION
FEDERALWAY,WA 98063-9718 �TY OF ��p
253-835-2607•FAX253-835-2609C B���p��yG T. / /
miuu�.cit�offederalu;n�.com
The ollowin is re uired i ormation-an incom lete a lication will not be acce ted. Please rint le ibl (in ink)or
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aiTE nn�xEss �1�SC� �i����' �-�,,� � ���r�:�l ��J��� (JJ� f�'JJJ suiTE�uxiT a 1 ���.
ASSESSOR'S TAX/PARCEL# Q �� c� � o �� - � � �Cr LOT SIZE(s,� �E� C� I �
LEGAL DESCRIPTION (e.g.Acme Estates,Lot I) ������'�C%`����
(Attnch separate page for lengthy legal descrfptioN
' • • ' •
TYPE OF PERNIIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING �I FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Prouide detailed description of work included on this permit onlu)
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PROJECT NAME(Name of Business or Owner Last Name) V L'4 �nc.,� �<'),�.r��",p��',�v C'+�� ' �r�r�2.�ix-� VV��.�
• • • � • _
PROPERTY NAME PRIMARY PHONE
OwivER �e,�`���c�,�1" ���urs�:��n^��,�t .L�� . ��s'i� ) v�-l�l - �jUr.�c�
MAILING ADDRESS CI1Y,STATE,ZIP
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CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
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L..�i7� :� ��';�P_f )C�,'�P_J ,�!':L .3t�'-�/� %�:7�.v,I�n, �_,�y 4x����)L� i`� - (�C7`1 r-i
MAILING DRESS CI1Y,STATE,ZIP CELL PHONE
i-'o �-,� �"�"��`a �--v�-a�r_:.1 U.���. lJ�;=} ��I�:;> ( ) -
� CPIY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPI ON DATE FAX NUMBER
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CONIRACTOR'S REGISIRAITON NUMBER(copy of cazd required with each applicatlon) EXPIRAITON DATE
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APPLICANT COMPANY NAME APPLICANT NAME OFFICE PHONE
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MAILING ADDRESS CI1Y,STATE,ZIP CELL PHONE
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RELA'IYONSHIP 1'O PROJECT FAX NUMBER
❑ Architect ❑ Tenant ❑Agent ❑ Other(Describe) ( � -
CONTACT NAME , PRIMARY PHONE E-MAIL ADDRESS
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o a �«�rzn��,r�, (����) �i`- - G��i�
LENDER NnME
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MAILING ADDRESS CI1Y,STATE,ZIP PHONE
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EXISTING USE PROPOSED USE
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EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $�
SPRINKLERED BUII.DING? �YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/RE9UIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER �LAKEHAVEN ❑ HIGFII.INE ❑ TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER LAKEHAVEN ❑ ffiGHLINE ❑ PRIVATE(SEPTIC)
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• • •• •
AREA DESCRIPTION EXISTING PROPOSED TOTAL
S .FT. S .FT. S .FT.
BASEMENT
FIRST
SECOND
THIRD
FOURTH
ADDITIONAL FIAORS(DESCRIBE)
DECK(COVERED?)
GARAGE ❑ CARPORT❑
ausrnvc raoeoaen rar,w �
NUMBER OF FLOORS �� ��t i �� 3 � °� �3+ ���n'"�� '�t�� � �,s��E��s'��� �.
- r� �� `�� ' �,�;t �ma rm � �� �"'
"'NEW HOMES ONLY'` NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
Indicate number of each type of fixture to be instailed or relocated as part of this profect. Do not inciude existing fixtures to remain.
MECHANICAL
Vaiue of Mechanical Work $
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(commemtaq WOODSTOVES
BOILERS FIREPLACE INSERT'S RANGES MISC(Describe)
COMPRESSORS FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUlY�ING
BATI�TUBS�or1Lb/ShowerCombo) SHOWERS WATER CLOSETS(roneq MISC(DeSCdbe)
DISHWASHERS SINKS DRINffiNG FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINAIS HOSE BIBBS
LAVS(Bathroom Stnks) VACUUM BREAKERS ELECTRIC WATER HEATERS
� •
I certi,fy under penalty o,f per,jury that the ir}formarion furnished by me is true and correct to the best of my knou�[edge, and further, that I
am authortzed by the o�uner of the above premises to perform the tuork for �uhich the permit application is made. I further agree to hold
harmless the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees tncurred in the investigation and defense of
such claim),u�hich may be made by any person,including the undersigned,and filed against the City of Federa!Way,but only where such claim
artses out o,f the reliance o the city,tncluding its o,�cers and employees,upon the accuracy oj the ir4formation supplied to the city as a part of
this application.
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NAME/TITLE `'�—-_ '�1 c.c,�.-} �/ 1�,.n.,,:<�_/ DATE �f�,L�V
(Signature) ('1'itle)
RELATIONSHIP TO PROJECT ❑ Owner ❑ P,gent � Contractor ❑ Architect ❑ Other
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Bulletin#100-January 1,2006 Page 2 of 4 k�I-Iandouts�Pernut Application