16-101447 • PERMITSPPLIr�ON
CITY OF
Federal Way MAR 2 4 2016
t ( - C ' 4 4 7- F p CITY OF FEDERAL WAY
PERMIT NUMBER ' J ( �I ! CDS
— TARGET DATE
SITE ADDRESS SUITE/UNIT#
53ti3L 4kAuE
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ Z c ` L c `1 L{ 5 C'1 - 0° , Q 0} Q_
TYPE OF PERMIT 0 BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT P{ rte,, �); (( �_\ , r. , M e rA
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PROJECT DESCRIPTION r
Detailed description of work to �� '11°--‹
( 1--c, Ex,i g V- , -c_7, r `J ` f-e.„-
be included on this permit only tl
NAME PRIMARY PHONE
cir1,
PROPERTY OWNER °. n\ ; �L A V L.I�- C_ "(5" i. l(',e_{ ` (:3'/1-...I-1
MAILING ADDRES1 E-MAIL
11vGJQ AlA '�
CRY ST TE. ZIP
NAME PHONE
U2. c__A-( ,._,\ Tom.ei-, oi()(3),, LL,(-- (i , s C35 46
MAILING ADDRESS ` E-MAIL
CONTRACTOR Po ))>'w I J e 7 `) Click ® �e.,4'c� --re-c)( -I�',
CITY 1 STATE zip-, FAX
WA!-._STATE
A CONTRACTOR'S- (-,c-,
LICENSE#�f EXPIRATION/200 FEDERAL I W(-) �,,.- ' LICENSE#
NAME/1 C PRIMARY PHONE ��
( .-IAC7c VThaUts .20(4, "131 ata
APPLICANT MAILING ADDRESS E-MAIL
0 C% (-, ) Lk P 1 LC* (V ( l, P k 14 ell' I e_cL, ,/3,Z-
CITY STATE ZIP FAX
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NAME PRIMARY PHONE
PROJECT CONTACT ' _ 41 -, "1';'- ----(
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 141 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP 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 Iaws 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 ci - qs a part othis ration.
SIGNATURE: / DATE y/Z cd ZCi i c,
PRINT NAME: C__.-11 r • S Dem 1I :
Bulletin#100—February 22,2016 Page 1 of 2 k:AHandouts\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 of fixture to be installed or relocated as part of this project.Do not include existingfuctures 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 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?
Yes ❑ No ❑Yes 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)
EXISTING PROPOSED TOTAL
Area Totals
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE$ #OF BEDROOMS
COMMERCIAL—NEW/ADDITION
AREA DESCRIPTION Area in Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
NEW BUILDING
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area in Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—February 22,2016 Page 2 of 2 161-landouts\Permit Application