15-106512 RECEIVII
cinr OF. '^°'_>:,, PERMI'1.APPLIGATIC)N
Federal Way DEC 2 3 2015
CITY OF FEDERAL WAY
/ 5— _ CDSPERMIT NUMBER /
TARGET DATE
SITE ADDRESSSUITE/UNIT#
l 3 / C.a 5 ' 3c)-S °'& � •
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ JO" lG.12 / `' 7 3 / E - 00 _Lo
TYPE OF PERMIT 0 BUILDING ❑ PLUMBING ❑ MECHANICAL 0 DEMOLITION ❑ ENGINEERING IRE PREVENTION
NAME OF PROJECTojc.....z_z_cd-z_m___ ��t64 .
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAMES (414--
/ PRIMARY PHONE
PROPERTY OWNER t/T'I) _,
MAILING ADDRESS V � E-MAIL
CITY STATE ZIP
NAME PHONE
MAILING ADDRESS11r_ E-MAIL l
CONTRACTOR 'Po Y�P' - 3Q/�� `CEM II�O9(J2-I.t� p�QniSpS\h(,cc_.
CITY STATE ZIP FAX
}- ctk,co—z7 ig2) 3g. _p (0 -5
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
ti-°-1°--)79 Z-3 GI 3 t1/ 1 t (
NAME C PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
• -OJECT CONTACT K i4 1 �''YYb4"?�I 2 13
(The in. Ulf/• - ' lle and MAILING ADDRESS E-MAIL
respond to all correspondence ICON �� (L' J )- ---
concerning this application) CITY J STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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 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 .f the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a p• of this application.
SIGNATURE: 4 if DATE
( DATE 1 2-1 2 '77/
Lc-
PRINT NAME: o� i
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application
• • 41101
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT
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(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 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 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 Occupancy Group(s) Construction #of Additional Information
in Square Feet Type Stories
NEW BUILDING
ADDITION
COMMERCIAL-REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area Occupancy Group(s) Construction #of Additional Information
in Square Feet Type Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—January 1,2013 Page 2 of 3 k:\Handouts\Permit Application