14-104715 �,rvoF
A. PERMIT APPLICATION
Federal Way SEP 1 2 2.014
CITY OF FEDERAL WAY
i
PERMIT NUMBER / q_ / 'i! 7 _5 _ F
lll/// ` (` TARGET DATE
SITE ADDRESS SUITE/UNIT#
3 20 c '3 Z e4
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$
2- C', -
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING 0�FIRE PREVENTION
NAME OF PROJECT 13 1\ Lk e- \\9 \ e-
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5-1- ,,p.i- a, mote
Ude �,A61 1 Nem aCO }-�(G1e Ana CA,t
PROJECT DESCRIPTION 11 ii -
Detailed description of work to 1r a t.'.'X 1 -,\ , op,
Cj�1�1"'C 'em�A�\ c I ,,,L 49 0 ry\
be included on this permit only 1 1
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
MAILING AD RESS G E-MAIL {•
CONTRACTOR C)4.
3� ��l (li�'',. e ;h-I-
t
, 'C(z 40. 4 • 131'1
CITY STATE ZIP FAX
II'-\\ CICA k-I, - rY.
WA STATE CONTRACTOR'S LICENSE# aXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
L- C i T '-1`{ 4 C. Ci- / /
NAME . PRIMARY PHONE
C \); 1`'. -C/a,1)15 2=('c^ -..,1 5 t 2_440
APPLICANT MAILING ADDRESS E-MAIL _
f 6 I cmc i-3`.14 It I c Nl(-(L; e.�l-, E e V .cl,,- B l z•
CITY STA
TE ZIP - FAX
4 , 1 C(`e.tt X11
-
NAME - PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.21095)
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 defens o such claim), whi h may be made by any person, including the undersigned, and filed against the city,
but only where such claim poises of the re iance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city art of this •pplication.
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SIGNATURE: . DATE c) / /Z, l ZO ) L\
PRINT NAME: G" " I c3 Dau i ..
Bulletin#100-January 1,2013 Page 1 of 3 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
VALUE OF PLUMBING WORK
PLUMBING PERMIT
Indicate how many of each type o f 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/Ut>7ity) 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