17-100035 dt
CITY OF `
410141 raji
PERMITPPLICATION
Federal Way J!', 0 ,) -PERMIT CENTER+33325 8th Avenue South + Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permltceriter ficityoffederalway.cotn
PERMIT NUMBER _ f Ob O`''5 �5 - c- p 011'c
TARGET DATE
SITE ADDRESS SUITE/UNIT#
3112 =xdhe - C vl-ex eI vd. FtdevaA Vvv4 onA4 R80a3
PROJECT VALUATION 41. ZONING ASSESSOR'S TAX/PARC s
$ 217 00 e 0 092_ 1 Qi-j_ j5
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING,FIRE PREVENTION
NAME OF PROJECT C,m 0-b n I n n
PROJECT DESCRIPTION S r act I b I t'16i� mon -1.17)r i n oS' rr1
Detailed description of work to 3 illy((,- 1 ems.
be included on this permit only
NAMEr` PRIMARY PHONE
PROPERTY OWNER Ct O 'Nv^l RS
MAILING ADDRESS E-MAIL
31120 pt}ewoco Cevie)r 731 vd. a 1 SartlammiirgAlp i-; too..
CITY STATE ZIP (071
Fedeta) .a. 9s00a
NAME PHONE
0UCu- ie e) Secvri tJv 2067.1a22•[p5y5
MAILING ADDRESS E-MAIL
CONTRACTOR
I��3 S •
od
CITY STATE ZIP FAX n' L • ♦iGl l�.; 'lX1a
S eat-ne. Ww1- 8)3
W,A CONTRACTOR'S�Z�‘C'S
�SE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
C7 /3() X2018
AME PRIMARY PHONE
61 Larclian Secvn Caet Se/ ibc - 20x0-(a 2Z-c95/5
APPLICANT MAILING ADDRESS d�J E-MAIL
114i?) I J4 ,e. S. Cie i an t,-c t y71
ITY
ZIP FAX
S' ". 0 C ai•I3CCrij
/ (,,NAME PRIMARY PHONE
C
PROJECT CONTACT E tD — 20(9'62Z21(2545 •.px f. .
(The individual to receive and MAILING ADD E-MAIL
respond to all correspondence �1'I Z? 15 Ave c� • eYtf�S root-PGy rC(;�lite-,
concerning this application) ot{,,M I 1 C STATE�/1,�- Z1 8 I ray FAX
C �
NAME
PROJECT FINANCING 0 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 79.27.095)
I certify under penalty of perjury that I am the property owner or authorised 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 authorised 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- ch c , which •. be made by any person,including the undersigned,and filed against the city,
but only where'such claim •/es out •f he reli• ce of the city, including its officers and employees, upon the accuracy of the
information supplied to ' = i _ as a ••• - on.
/�i
SIGNATURE: i �tf� �� �, z 1 (Q
DATE Z
Or
PRINT NAME: - 1! t Fen /z)C-
Bulletin#100—January 29,2016 Page 1 of 2 k:\Handouts\Permit Application
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT $
Indicate how many of each type offixture to be installed or relocated as part of this project.Do not include existing 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
VALUE OF PLUMBING WORK
PLUMBING PERMIT
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/uteity) 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?
1o2 i 1-12-Q9- -4- o Yes ❑ No ❑Yes 0 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 0 CARPORT 0
OTHER(describe)'
Area Totals EXISTING PROPOSED TOTAL
**NEW HOMES ONLY** —
ESTIMATED SELLING PRICE$ #OF BEDROOMS
COMMERCIAL—NEW/ADDITION
Area in Construction *of
AREA DESCRIPTION Occupancy Group(s) Additional Information
Square FeetType Stories
NEW BUILDING
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area in Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories h
TOTAL BUILDINGli/ (f-l 5 +1 H` `p
/(
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—January 29,2016 Page 2 of 2 k:\Handouts\Permit Application