09-104874 (2)T, E R M I T�� S w MF CO /ME�EL PPL DE EN P
Federal VIP E C E I V C� D
WMM0NnynE1(iWpM&W&"WcES AhrPLICATION
2sa-835-2607• FAX 2S4-89S2609 DEC 16
SITE ADDRESS r
7z(a [ �t
SUITE/UNIT #
NAME OF PROJECT
(Tenant or Homeowner Name)
TYPE OF PERMIT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
OWNER IS ALSO:
CONTRACTOR
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
Required for projects with
value of $5,000 or more '
(RCW 19.27.095)
IERAI WAY PROPERTY
1$ & D
ZONDi0 ASSESSOR'S TAR/PARCEL #
L15-- 2- L/- U L O
PROJECT
�f'o
{3 BUMDING pLYJmMG *N[ECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION
as
C-
PEOPLE
NAME
MAnMG ADDRESS, CITT, STATE, ZIP
—, % i
p CONTRACTOR
NAME
AT n
MAILING ADDRESS, CITY, STATE, ZIP
WA STATE CONTRACTOR'S LICENSE #
NAME
MAILING ADDRESS, crrT, STATE, ZP
NAME
a ti•
MAILING ADDRESS, CITY, STATE, ZIP
ALTERNATE CONTACT RAMS:
NAME
a—k �� �- �
MAILING ADDRESS, CITY, STATZ. ZIP
rr
p APPLICANT
�-e-
W R ci & 3
EXPIRATION DATE
y�- 0C,
LL d-
PRIMARY PHONE
ZD .
PRIMARY PHONE
t740 ) 344 - 792
E-MAH,
PROJECT CONTACT
PRIMARY PRONE
FAX
FEDERAL WAY EIISBUM LIC
22g< 7
PRIMARY PHONE
o�z-
FAX
PRIMARY PHONE
, 6 4 - S4E
FAX
E-MAM
OWNER-MANCED
PROiARY PHONE
I certify under penalty of perjury that I am the property owner or authorised agent of the property owner. I certify that to the
best of my knowledge, the Wormation submitted in support of this ,permit application is true and correct. I certify that I will comply
with all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that
the issuance of this permit doss not remove the owner's responsibiiit]y for compliance with local, state, or federal laws regulating
construction or environmental Iaws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorreeya' 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, but only whargAiAch claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
Ir4formatton suppi d�a the cittas� part of this application.
#
Indicate number of e h
AIR HANDLING UNITS
AIR CONDITIONER
BOILERS
COMPRESSORS
DUCTING
Indicate number of each tJpe c
BATHTUBS 1� n,n/shower Combo)
DISHWASHERS
DRAINS
DRINKING FOUNTAINS
HOSE BIBBS
FRO,IEpT VALIIATION
�S'�'tOIFREVIOrIs IISE
fir+; 14es.
MECHANICAL FIXT!]BFS
ical Work $ �C U
-------------
a re to be installed or relocated
A PY OF BID OR
as PRpTr�p
part o this roBlr
FANS p �D�ot includefixtures to
INSERTS
GAS PIPE
remainFIREPLACE
IdOODS OTHER (Describe)
FURNACES
GAS LOG SETS
HOT WATER TANKS pq—_--
GAS PIPING
REFRIGERATION SYST — — -
WOODSTOVES
PLUMBING
FJ"�tre
FIXTURES
to be installed or relocated
—� LAVS IHm,a shy
as p� of this pm'
J�Do not include existin res to
RAINWATER SYSTEMS
SHOWERS
—..L. ToILEMremain.
WATER PIPING
URINALS
�L
S
VACUUM B OTHER (Describe)
BEAKERS
INKS IK:tchen/Nwtryl
SUMPS WATER HEATERS
WASHING MACHINES
GENERAL INFORMATION
WATER ruji zvoit
SEWER PURVEYOR
aet
TOTAL F rrURM
VALUX OF BMW ING DfpIIOVNWM
LOT SIZE (In s9n.� F" "' b i
EBISTDiO FIRE BPRIIiZdgR 3YSTE1IP PRO;
FIRE S
' 4, ezt ❑ Yes X NO u"FESSION SYSTEM?
c� Yes ❑ No
ARC n> �TIOx (in square
BASEIWIENT
FIRST FLOOR (or Mobile blame)
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
Area Tota l
PRICE
RESIDE,NTIA L
E71387'�i[i 1�ROP'Q,�17 TOTAL
# OF BEDROOMS
FOR
ARIA DESCRMT101, AreaC'OMM E R CIAL — NEW/ADDITION
NlEW SMI)ING In unre Feet Occupancy Group(s) Construction # of
Stories Additionallnformation
ADDITION
COMMERCIAL — RENIODCkrpprlt I
AREA DER1pI`ION Area NANT IMPROVEMENTS
Ints vaFeet Occupancy Group(a) ConstructionTOTAL BUILDING isiOrlea Additional IIIf011natjOA
TENANT AREA ONLY
ONLY
Bulletin #100—11/25/2009
Page 3 of 4
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