21-103967-PERMIT APPLICATION-9-24-21-v1CITY Of ° Federal Way
PERMIT APPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter!dcityoffederalway.com
PERMIT NUMBER "L O _ 1 0 �L o ,6 �f _ O
2-TARGET DATE
SITE ADDRESS
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SUITE/UNIT #
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARC�EyL #
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING XMECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
C' V., cl V OLT,C, G C
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
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NAME :5 �.0s
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS �{- A N
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E-MAIL
CITY
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STATE
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ZIP
NAME
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MAILING ADDRESS
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E-MAIL
CONTRACTOR
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STAVE
ZIP
FAX
Ied'yWA STATE CONTRACTOR'S LICENSE #
CC 0A�)AA" L95S_ )r- cL
EXPIRATION DATE
5 2& x?
UBI #
6 1D,3 — Sbo - 5-61
NAME 0 H V w
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PRIMARY PHONE
APPLICANT
LING ADDRESS
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E-MAIL
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ZIP 3 + �
FAX
PROJECT CONTACT
NAME
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PRIMARY PHONE
MAILING ADDRESS
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E-MAIL
(The individual to receive and
respond to all correspondence
CITY reJ J
t(a-�
sT�yTE
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ZIP
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FAX
concerning this application)
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 tht 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 part of this application.
SIGNATURE: DATE 24 - Z 1
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PRINT NAME: o n QS � 5 u C r0
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Bulletin #100 - February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application
-MECHA.NI(CAL PERMIT
Indicate how many of each typ
AIR HANDLING UNITS
AIR CONDITIONER
BOILERS
COMPRESSORS
DUCTING
PLUMBING PERMIT
fixture to be installed or relocated as
FANS '1
FIREPLACE INSERTS _
FURNACES _
GAS LOG SETS _
GAS PIPING
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS (or Tub/shower combo) LAVS (Hand sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS (Kitchen/Utility) WATER HEATERS (Electric)
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 SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
❑ Yes ❑ No
COMMERCIAL - NEWADDITION
AREA DESCRIPTION Area in Occupancy Group(s) Construction # of Additional Information
Square Feet I I Type I Stories
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area in Occupancy Group(s) Construction # of
Square Feet Ty»e Stories Additional Information
TENANT AREA ONLY
Bulletin #100 — February 19, 2020 Page 2 of 2 k:\Handouts\Permit Application