17-104416 RECEIVE
AIL SEP 13 2011 PERMIT APPLICATION
CITY OF orf'
CITY OF FEDERAL WAY PERMIT CENTER+ 33325 8th Avenue South + Federal Way,WA 98003-6325
Federal Way COMMUNITY DEVELOPMEN 253-835-2607 + FAX 253-835-2609 +permitcenteracityoffederalway.com
PERMIT NUMBER / 47 - / 0 9 ( / 6, - , to (---------
TARGET DATE
SITE ADDRESS SUITE/UNIT#
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 2 / ova oo 7 g 1 Off d - O a- V o
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING N IRE PREVENTION
NAME OF PROJECT eG r 7-- � v
PROJECT DESCRIPTION
ITA S ; N 44/ �i A t re ,C/re 3-5 r�c'." S. ,' �+ILt
Detailed description of work to ✓ G GCS 7C7,c" CC.""f/_)C7 °' e-v',
be included on this permit only
iebAcl tri� 1 epi JI% :Y 4/- 71-e,/et
NAME k9a„^1 PRIMARY PHONE
PROPERTY OWNER MAILING ADDRESS <-:C-( E-MAIL
CITY /-� STATE ZIP { '-'
NAME / L/ /) /4 00,-{ ii., • 7 e(i{J�'1 PHONE06' 5-,-)- S l
MAILING ADDRESS E-MAIL
7
CONTRACTOR �- '16/ l' ?< /,/C' �`'rrv� �t���•,rCCv' f24'/
CITYSTATE ZIP FAX
� i 7�� uz,,' v/oma
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
NAME PRIMARY PHONE "? G
Q �� 6 U� /yn 2' C - -57‘9?
APPLICANT MAILING ADDRESS , !/ E-MAIL
1 ( 0( 2 - !f c.C_ S. A a4)-4,4c/421 :1,4,....(,
CITY /I (c STATE ZIP4144 / 68 FAX CU,
NAME �._ PRIMARY PHONE
PROJECT CONTACT i ' /Y1 C' ‘-i <T ar/ CC-,A -
(The individual to receive and MAILING ADDRESS / E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCINGA-y/1 ❑ 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 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: Z! DATE (9 -/ 2 `/ -
PRINT NAME: C//,/G '7 G'v n Z2'—e
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 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
I VALUE yrPLUMBING WORK
P ' IT I
Indicate how many o -ach type of fixture to be installed or relocated as part of this project. o not include existing fixtures to remain.
BATHTUBS(or Tub/Sho•-r Combo) LAVS(Hand Sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS/ OTHER(Describe)
DRAINS SHOWERS VACUA!BREAKERS
DRINKING FOUNTAINS SINKS(Kitchen/Utility) WWfER HEATERS(Electric)
HOSE BIBBS SUMPS ,,,4VASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY? WATER PU=. YOR SE PURVEYOR VALUE OF EXISTING IMPROVEMENTS
$
EXISTING/PREVIOUS USE LOT SIZE(In Square eet) /., EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑Yes ❑ No ❑ Yes n No
/�
1 RESIDENTIAL - NEW OR ADDITI0
AREA DESCRIPTION(in square feet) EXISTING \'ROPOSED TOTAL FOR OFFICE USE
BASEMENT
FIRST FLOOR(or Mobile Home)
SECOND FLOOR ,
j
COVERED ENTRY
DECK r
GARAGE ❑ CARPORT ❑
OTHER(d cribe)
EXISTING PROPOSED TOTAL
Area Totals
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE$ # OF BEDROOMS
COMMERCIAL—NEW/ADDITION
Area in I Construction #of
AREA DESCRIPTION RznarP Feet Occupancy Groups) ,r,,Yc Stories Additional Information
NEW BUILDING
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area in Occupancy Group(s) Construction #of Additional Information
Square FeetType Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—January 29,2016 Page 2 of 2 k:\Handouts\Permit Application