12-101737 1O ( 7 � 7
CITY OF MF CO ME PL DE E
Federal Way �(�
COMMUNITY DEVELOPMENT SERVICES APPLICATIONET V
ED
253-835-2607•FAX 253-835-2609
wunwd tso ffeder aluajont
APR 1 8 2042 ,q�
SITE ADDRESS SUITE/UNIT#
3I a a U� AV Si F'sDER Ae_ wigv !CITY OF FEDERAL WAY
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL if CDS
$ /00 v •2 / D q - 9 0 / 9
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
❑ DEMOLITION 0 ENGINEERING ® FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) PM-LA
c_C B e)Q
PROJECT DESCRIPTION PDD A 'T'Aty lL TO SUPPORT EXt Sr (t.NG APDL!A I4Ci
Detailed description of work to FLOW PO t NT S P£R coDE R EM o h.)O IRO Z ZLE.s
be included on this permit only
PR6I-E_c'r(NI G NCTNlNG
NAME PRIMARY PHONE
PROPERTY OWNER V E R NIG I,J-r f G MY.
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
AGLASS FIRE Pr.o-rEc logy sacs 42$ '/(3 .2.6gg'
MAILING ADDRESS E-MAIL�, ��
CONTRACTOR Po a 6 X 757 3 Gov p►� �e CT!O f'',cD M
CITY STATE ZIP 9
^ O
COvtNG tZ5rJ buA
WA STATE CONTRACTOR'S LICENSE 8 EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE 8
NAME PHONE
C-0 ArT72A-C-TO g.
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT
NAME 3.N-ANn)o.1G R ti_ Gt-i-E RNo F F PHONE��s-q(3 2(P 1{'8'
(The individual to receive and
respond to all correspondence MAILING ADDRESSar
EMAIL
concerning this application) 5 `0_
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
OWNER-FINANCED
Required value of$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 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 a part of this application.
SIGNATURE: (2 6
DATE T/( TA 2
PRINT NAME: SNNoNIGA-rl_ til#'EQLVO F F
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application
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VALUE OF MECHANICAL WORK $ (a copy of bid or estimate must be provided)
Indicate how many of each type of fixture 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(Gan)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate how many of each type of fixture 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 •;;'w•:' C1t1'&fiIIE
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£
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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
AREA DESCRIPTION(in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
iz
FIRST FLOOR(or Mobile Home)
COVERED ENTRY
GARAGE ❑ CARPORT ❑ ___
,
e
•
EXISTING PROPOSED TOTAL
Area Totals
ESTIMATED SELLING PRICE$ #OF BEDROOMS
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
in S.uare Feet •e Stories
Y..
gg >;pE«m
ADDITION
Y
x � i
AREA DESCRIPTION IMIRI
Occupancy Group(s) Construction St ries Additional Information
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Bulletin#100—January 1,2011 Page 2 of 3 k:\Handouts\Permit Application