21-100167_Permit_Application_Chernikov_210112_v10
PERMIT NUMBER
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
- TARGET DATE
SITE ADDRESS
+-ASSESSOR'S
SUITE/UNIT #
PROJECT VALUATION
ZONING
TAX/PARCEL #
TYPE OF PERMIT
BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME I
PRII
Y PHONEPROPERTY
fM�
OWNER
MAILING ADDRES//S�S �j - �y 1
"l " 7W �,
E-MAD,
LM i kb ") v %e
CITY y
l {
STA
ZIP
n
NAME
PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
UBI #
NAME
PRIAWYPHONE
APPLICANT
MA�IiLI,NG ADDRESS
CITY.
STAT
ZIP
FAX i
PROJECT CONTACT/
NAME _
- (� �i.(f (�L— -
_PRIMARY PHONE
(The individual to receive and
respond to all correspondence
MAILING ADDRESS $ /� }� )/��
I��11r'� ' �Q A�� �; T' �I(� 71
:
concerning this application)
CITY
STAT
ZIP
FAX
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information 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 does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless 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,
but only where such claim arises out of the reli ce of a city, including its officers and employees, upon the accuracy of the
information supplied to the city as apart of this pplication.
J
i
SIGNATURE:
DATE
\ L i�
PRINT NAME: V �N� Yy�1Ch(/� r YIA Itch
M
Bulletin # 100 — February 19, 2020
Page] of 2
k:\Handouts\Permit Application
MECHANICAL PERMIT
VALUE OF MECHANICAL WORK
� 4,
��
Indicate how man o each e o
re to be installed or relocated
as art o this ro'ect. Do not include a dsh
res to remain.
AIR HANDLING UNITS
FANS
Z GAS PIPE OUTLETS
OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS
HOODS (commercial)
BOILERS
_� FURNACES
�_ HOT WATER TANKS (G-)
COMPRESSORS
GAS LOG SETS
REFRIGERATION SYST
_I__ DUCTING
GAS PIPING
WOODSTOVES
PLUMBING PERMIT
VALUE OF PLUMBING WORK
$
Indicate how many of each e of
fixture to be installed or relocated as part of this project. Do not include existing tures to remain.
BATHTTJBS (or Tub/Shower Combo)
LAVS (Hand Sinks)
TOILETS WATER PIPING
DISHWASHERS
�T
RAINWATER SYSTEMS
-�� URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen/Utility)
WATER HEATERS (electric)
%i HOSE BIBBS _ SUMPS WASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR //
SEWER�PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
EXISTING/PREVIOUS USE
�—� LOT,
LOT SIZE (In Squaze Feet(
EXISTING FIRE 8 M MER SYSTEM?
❑ Yes No
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes x No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet) EXISTING PROPOSED I TOTAL FOR OFFICE USE
......... ..... ...
FIRST FLOOR (or Mobile Home)
COVERED ENTRY
CARPORT El
Area Totals
WIN6
-
Frg ,inK )9
EXISTING
PROPOSED
TOTAL
ESTIMATED SELLING PRICE $ (-, I'/�[J� ( # OF BEDROOMS 'r / (
Bulletin # 100 — February 19, 2020 Page 2 of 2 k:\I-iandouts\Permit Application