11-105090CITY OF "' a.-''
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253-835-2607• FAX 253-835-2609
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PERMIT
APPLICATION
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DEC 2 3 2011
SITE ADDRESS CITY OF
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ 7 z "�j 'q a
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION 21 ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
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NAME
PRIMARY PHONE
PROPERTY OWNER
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G ADDRESS
3 32- Ave,
E-MAIL
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CITY
STATE ZIP
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NAME
PHONE
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MAD.ING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
ERPIItATION DATE
FEDERAL. WAY BUSINESS LICENSE #
NAME
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PHONE
253-93S=z7ZZ
APPLICANT
MAD.LNG ADDRESS /
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E-MAIL
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Cr"STATE
ZIP
FAX
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PROJECT CONTACT
NAM
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PHONE
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(The individual to receive and
respond to all correspondence
MAILING ADDRESS „
E-MAIL
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concerning this application)
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STATE
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FAX
ALTERNATE CONTACTNAME:
PHONE
E-MAIL
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PROJECT FINANCING
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OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADbRESS. CITY. STATE. 2IF
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 reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as apart of this application.
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SIGNATURE: DATE
PRINT N tin
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Bulletin #100 -January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
MECHANICAL FIXTURES
VALUE OF MECHANICAL WORK `
fa copy of bid or estimate must be prOUfdeW
Indicate how many of each type offixture to be tnstatied or relocated as part of this project. Do not include e-xistingfikbims to remain.
AIR HANDLING UNITS
FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS HOODS (commercial)
BOILERS
FURNACES HOT WATER TANKS (cas)
COMPRESSORS
GAS LOG SETS REFRIGERATION SYST
DUCTING
GAS PIPING WOODSTOVES
PLUMBING FIXTURES
Indicate how many of each type of jbgr we to be installed or relocated as part of this project Do not include existing fixtures to remain.
BATHTUBS (or Tub/Showcr Combo) LAVS (Hand Sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS (Kimhcn/Utimy) WATER HEATERS (E[cctric)
HOSE BIBBS SUMPS WASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
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9
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes No
❑ Yes W No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
BASEMENT
FIRST FLOOR (or Mobile Home)
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
Area Totals
EXISTING
PROPOSED
TOTAL
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE $
# OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
Stories
Additional Information
NEW BUILDING
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
# of
Stories
Additional Information
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin # 100 -January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application