09-104434EC ',' LJ
PERMIT
CITY OF
Federal Way '�NOV 1 2, nOirlS
COMAI1N)7YVVVEWpME FSEWrMS APTALICATION
25s �20F FEDE
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SITE ADDRESS
17,�0
SF MF CO ME EL PL DE EN I'P
1 1
SUITE/UNIT # ZONING IASSESSOR'S TAX/PARCEL #
NAME OF PROJECT �—
(Tenant or Homeowner Name)
❑ BUILD G ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT ❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING 4xIRE PREVENTION
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
OWNER
NAME
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PRIMARY PHONE
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PROPERTY
MAD.INGADDRESS, CITY, STATE. ZIP
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E-MAIL
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❑ CONTRACTOR
APPLICANT
PROJECT CONTACT
OWNER IS ALSO:
NAME
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,�rt�� �1 � ianl
PAI)WARY PHONE
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CONTRACTOR
UALLING
ADDRESS, CITY. �S^TATE�, ZIP
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- i�77
WA §TATZ CplWI'RACTOWS LICENSE #
A FVA 1ul� P Of F6
EXPDiATION DATE
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FEDERAL WAY BUSUMSS LICENSE it
1� �� - a0lob0T
— -
NAME
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PRIMARY PHONE
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APPLICANT
,
MAILING ADDRESS, CITY, STATE, ZIP
L14 qp
FAX
PROJECT CONTACT
NAME
I (
` �
PRIMARY PHONE
( T - r 17
(The individual to receive and
respond to all correspondence
concerning this application)
MAILING ADDRESS, CITY. STA E. ZIP
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FAX
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ALTERNATE CONTACT NAME:
PHONE
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1PRIMARY
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LV
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PROJECT FINANCING
NAME
OWNER -FINANCED
Required for projects with
value of $5,000 or more
MAILING ADDRESS. CITY, STATE, ZIP
PRIMARY PHONE
(RCW 19.27.095)
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.
]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
h
information supplied to the city as apart of this application.
SIGNATURE: DATE
PRINT NAME: i
Bulletin #100 — 4/21/2009 Page 1 of 4 k:\Handouts\Permit Application
MECHANICAL FIXTURES
Value of Mechanical Work $ fA Copy OF BID OR ESTIMATE MUSTBE PROVIDED)
Indicate number of each type of jxture to be installed or relocated as pout aJ this project. Do not include exist fixtures to remain.
AIR HANDLING UNITS
FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS HOODS (commercial)
BOILERS
FURNACES HOT WATER TANKS (Gas)
COMPRESSORS
GAS LOG SETS REFRIGERATION SYST
DUCTING
GAS PIPING WOODSTOVES
PLUMBING FIXTURES
Indicate number 91 each q0 of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS (or7Lb/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
PROJECT VALUATION
WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
$
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
41. ❑ Yes>CNo (Yes ❑ No
RESIDENTIAL
AREA DESCRIPTION (in square feet) EXISTING I PROPOSED I TOTAL FOR OFFICE USE
FIRST FLOOR (or Mobile Home)
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
Area Totals
rmsrrnc paovoasn :nr�u. — — •-- --
"NEW HOMES ONLY,
=MATED SELLING PRICE § # OF F3P;1]KUUira7
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION Area Occupancy Group(s) Construction # of Additional Information
in Nuare Feet Type Stories _
NEW BUILDING
ADDITION
COMMERCIAL -- REMODEUTENANT IMPROVEMENTS
AREA DESCRIPTION Area Occupancy Group(s) Construction # of Additional Information
in Square Feet a Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin #100 — 4/21/2009 Page 2 of 4 k:\Handouts\Permit Application