11-105016 1 ( - `I O. 5O I (0
coir of VV+ ��iv E R M I 1111\4F CO ME PL DE EN FP
Federal
COMMUNITY DEVELOPMENT SERVICES APPLICATION
A
p p L I C A T I O N aCA- -P
253-835-2607• 253-835-260EC 23 Guwuu.rito(federvluat LonW/>'IT /
r •
-IN Of FEDERAL WAY , 1
SITE ADDRESS S T' NI #
/6:17 C g)S -7/L/ 4
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ i( C' —
TYPE OF PERMIT IDBUILDING ❑ PLUMBING 0 MECHANICAL
❑ DEMOLITION 0 ENGINEERING MIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) J ) ( "1‘,4,—
f/
V. l/ail r�c� 7'0 12- r.emac,`
PROJECT DESCRIPTIONpt r� K� % / S , 2 t / /
Detailed desert tion ofwork to v>'�/ G MO C7Fsf rs `�/0 ,ri i -
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
14' Ve 616- & �r 0/2—/ -Tre zS3 3i S' i
MAILING ADDRESS E-MAIL
CONTRACTOR `�v1>° /16. S-! C-- (=
C / STATE ZIP FAX
%/ C.... IC •S 'r 7S-? Fq/ ci ;
WA STATE CONTRACTOR'S LICENSE�S # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
•
V V: ( � � F.!s'. /
NAME PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and JCS- 3%-r
respond to all correspondence MAILING ADDRESS EMAIL
concerning this application)
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: Ll/L 7/ 1 DATE / L f 1 1�A
PRINT NAME: / /!9r`� $/4(."
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application
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(H—-HANK. . IXTUR ;;
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(Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
.,.. PLUi�IBING FIXTURES ,.
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 j 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 0 No
RESIDENTIAL NEw OR ADDITION ,
AREA DESCRIPTION(in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
.ribs
BASEMENT
FIRST FLOOR(or Mobile Home)
1,°` g :LOOR" .. F
COVERED ENTRY
DECK - _-- — --------
GARAGE LI CARPORT ❑
OTHER(describe)
HXISTIHG PROPOSED TOTAL
Area Totals
**NEWHOMES ONLY**
ESTIMATED SELLING PRICE$ # OF BEDROOMS
� . `fi COMMERCIAL- 'ATE '/ADDI1 IOti
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
in Square Feet Type Stories
NEW BUILDING
ADDITION
CO kli)IFRCI AI_,- REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area Construction # of
Occupancy Group(s) Additional Information
in Square Feet Type Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY s
Bulletin#100–January 1,2011 Page 2 of 3 k:\Handouts\Permit Application