21-100168_Permit_Application_Lisitsyn_210115_v1113
4k
CITY OF
Federal Way
PERMIT NUMBER
PERMIT APPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcente acityoffederalway.com
TARGET DATE
SITE ADDRESS
: I7 S -r•�4r// / �1 t l/� �V
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT`
PROJECT DESCRIPTION
1, i
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
( l
PROPERTY OWNER
MAILING ADDRESS
. _�
MAUI
q
CI
STAT
ZIP
I'P
NAME
PHONE
MAILING ADDRESS
E-MAILCONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
UBI #
NAME �-y `� • (�
P Y PHONE
APPLICANT
MAILING ADDRESS
CITY j�
STAT
ZIP
FAX
PROJECT CONTACT
NAM
s
UtzAl —
Y PHONE
Fj 2j — �f
(The individual to receive and
MAILING ADDRESS )
' —� *— v
`L—
respond to all correspondence
�`.Q Q.
S
concerning this application)
CITY
STAT
ZIP__T
FAR
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 1 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 reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a pa of this application.
1 C %�
SIGNATURE: DATE �/ / . ZW,,'
PRINT NAME: 75'-.l T
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0
Bulletin #100 — February 19, 2020
Page 1 of 2
kAHandouts\Pennit Application
MECHANICAL PERMIT
Indicate how many of each typ
AIR HANDLING UNITS
AIR CONDITIONER
BOILERS
COMPRESSORS
I DUCTING
to be installed or relocated as
FANS _
FIREPLACE INSERTS
y
FURNACES _
GAS LOG SETS s
GAS PIPING
PLUMBING PERMIT
VALUE OF PLUMBING WORK
$
Indicate how many of each type o tore to be installed or relocated as part of this project. Do not include ex'isting ftctures to remain.
BATHTUBS (or7 b/shower comho) LAVS (e—a sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS A9' URINALS OTHER (Describe)
BRAINS �f SHOWERS VACUUM BREAKERS
���DRINKING FOUNTAINS SINKS (Kitchen/Utstyl —40'— WATER HEATERS (Electric)
�a HOSE BIBBS SUMPS WASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL FERTY?
WATER PURVEYOR ?
1�& 4i�4
SEWER
IEW)E iR`PURVEYOR
LA-V,) t [�*,4
VALUE OF EXISTI�N..,G IMPROVEMENTS
$ —&
EXISTING/PREVIOUS USE
V"Xtc LOT
LOT SIZE (In Square Feet)
I I�
EXISTING FIRE SP ER SYSTEM?
❑ Ye 0
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes Po
Bulletin #100 - February 19, 2020 Page 2 of 2 k:\Handouts\Permit Application