11-105087CITY OF
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
AY
1PEDMA L WAY
PROJECT VALUATION
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ASSESSOR'S TAX/PARCEL #
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❑ BUILDING
❑ PLUMBING
❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION
®' ENGINEERING
❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/HomeownerJ
Last Name) ! s 1) �� 7 � l�Gt 9 o
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PROJECT DESCRIPTION
D t i1 d
n es
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be included on this permit only
PROPERTY OWNER
CONTRACTOR
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
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NAME PRIMARY PHONE
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MAMM ADDRESS E-MAIL
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CITY STATE ZIP
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PHONE
NAME �}
T w f !X
MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
WA STATE CONTRACTOR'S LICENSE #
NAME
MAILING ADDRESS J
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CITY
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NAME
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MAILING ADDRESS p �}
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EXPIRATION DATE I FEDERAL WAY BUSINESS LICENSE #
STATE ZIP
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PHONE
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E-MAIL
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FAX
PHONE
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E-MAIL
CITY �y STATE ZIP FAX
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ALTERNATE CONTACT N I PHONE E-MAM
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PROJECT FINANCING NA p i f OWNER -FINANCED
el
Required value of $5,000 or more eJ W
(RCW 19.27.095)
MAILING ADDRESS, CTTY. STATE, ZIP PHONE
I certify under penalty of perjury that I um the property owner or authorized agent of the property owner. I certM 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. andfiled 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
ir1ormation supplied to ter ty�a & part of this application.
SIGNATURE: - �• Chu ' DATE
PRINT N V L)
Bulletin #100 —January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
W�
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VALUE OF MECHANICAL WORK
Indicate how many of each typep fi
_ AIR HANDLING UNITS _
_ AIR CONDITIONER _
_ BOILERS _
COMPRESSORS _
DUCTING _
Indicate how many of each typo
_ BATHTUBS (or Tub/Shower Combo)
_ DISHWASHERS
_ DRAINS
_ DRINKING FOUNTAINS
HOSE BIBBS
MECHANICAL FIXTURES
L- (a eopy of bid or estimate must be provided
to be rwtatied or relocated as part of this projeet. Do not include
FANS GAS PIPE OUTLETS _
FIREPLACE INSERTS HOODS (commercial)
FURNACES HOT WATER TANKS (Gas)
GAS LOG SETS REFRIGERATION SYST
GAS PIPING WOODSTOVES
PLUMBING FIXTURES
to be installed or relocated as part of this project. Do not include
LAVS (Hand Sinks) TOILETS _
RAINWATER SYSTEMS URINALS _
SHOWERS VACUUM BREAKERS
SINKS (Mlehen/utilnyl WATER HEATERS (Electric)
SUMPS WASHING MACHINES 1
GENERAL INFORMATION
I f8atures to remain.
OTHER (Describe)
eg fixtures to remain.
WATER PIPING
OTHER (Describe)
TOTAL FIXTURES
CRM AREAS ON PI�OPERTY? WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
ur 114.�4( 1� Jlf,/ixidmf
G/pRewous USE LOT SIZE (In Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
n/ ///t- ❑ Yes 29 No ❑ Yes X No
RESIDENTIAL - NEW OR ADDITION or
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) _
EXISTING PROPOSED TOTAL
Area Totals
**NEW HOMES ONLY*'
r-5rnMA'I`RD SELLING PRICE S # OF BEDROOMS
Bulletin #100 — January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application