04-101635 • RECEIVED CONSTRUCOON PERMIT APPLICATION
CITY OF ' 3...-=r- '� "APPLICATION NUMBER: <� - f O j_6S3-= _Fp= �
Federal Way ``PR 3 Q 2004 APPLICATION NUMBER: - -
( ITY OF FEDERAL WA' APPLICATION NUMBER: - -
BUILDING DEPT
**The followings required Information—Please print(in ink)or type**
Please note: Electrical,Fire Prevention Systems and Engineering permits may require a separate application.
• PROPFRTY INFORMATION
SITE ADDRESS: 34515 9th Avenue South ASSESSOR'S TAX/PARCEL#:7 5 0 4 5 1 - 0 0 2 0
LEGAL DESCRIPTION OF SUBJECT PROPERTY(ATTACH SEPARATE DESCRIPTION IF LENGTHY):
PROJECT INFORMATION
TYPE OF PROJECT(This application): ❑ BUILDING ❑ PLUMBING MECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING RE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description):
MEDICAL GAS
ST. FRANCIS HOSPITAL - SURGERY
PROJECT NAME:
■ PROJECT INFORMATION
PROPERTY OWNER: NAME: DAYTIME PHONE:
ST. FRANCIS HOSPITAL ( ) -
MAILING ADDRESS STREET ADDRESS;CITY,STATE,ZIP):
345u3 9th Avenue South #320 - Federal Way, WA 98003
CONTRACTOR: NAME: (360 DAYTIME )692 - 6128
HONE:
STIRRETT JOHNSEN INC.
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
5555 WESTGATE ROAD NW, SILVERDALE, WA 98383 (360 )692 - 6128
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER: FAX NUMBER:
0 4 - 1 0 0 2 0 Q - Q _D ( 360 ) 698 - 1832
CONTRACTOR'S REGISTRATION NUMBER: EXPIRATION DATE:
(copy of card required) .5 Z I R R J * 2 _ 1 -3 _i 05 X01 / 04
APPLICANT: NAME: DAYTIME PHONE:
. STIRRETT JOHNSEN INC. ( 360 ) 692 - 6128
MAILING ADDRESS(STREET ADDRESS;CITY,STATE,ZIP): EVENING PHONE:
5555 WESTGATE ROAD NW, SILVERDALE, WA 98383 ( 360 ) 692 6128
RELATIONSHIP TO PROJECT: FAX NUMBER:
❑ARCHITECT ❑TENANT - OTHER(DESCRIBE):C C ti t Mt\C 1 ZA` (3(t( )/7j'- f 3S;3
E-MAIL ADDRESS:
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ❑APPLICANT D:CONTRACTOR v.E.s 1 rtitC II C�U�`i,
IN PROJECT INFORMATION
EXISTING USE: HOSPITAL EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: $ £00-2- 6 0
SPRINKLERED BUILDING? td YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: o YES o NO
WATER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER: ❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE(SEPTIC)
S N
I **NEW RESIDENTIAL CONSTRUCTION OW** •
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
■ PROJECT FLOOR AREAS
FLOOR EXISTING SQ.FT. PROPOSED SQ.FT. TOTAL
BASEMENT
FIRST
- -
SECOND
THIRD
FOURTH
/ - -
OTHER FLOORS(DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
1 FIXTURES ';`-3
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS LOG(S) REFRIG.SYSTEM(S)
BBQ(S) FAN(S) HOOD(S) WOODSTOVE(S)
BOILER(S) FIREPLACE INSERTS) RANGE(S) MISC.( )
COMPRESSOR(S) FURNACE(S)
DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: ❑ ELECTRIC ❑ GAS
PLUMBING
BATHTUB(S) LAVATORY(S) URINAL(S) WATER HEATER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) ❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINK(S) WATER CLOSET(S) MISC.( )
INTERCEPTOR(S) SUMP(S)
A DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge,and
further,that I am authorized by the owner of the above premises to perform the work for which the permit application is made. 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 of
Federal Way,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.
NAME/TITLE: �"t -r— / IP
f DATE: �`
.2s- V
❑ PROPERTY OWNER o APPLICANT ONTRACTOR
FOR OFFICE USE ONLY:
❑ NEW ❑ ADDITION 0 ALTERATION ❑ REPAIR ❑TENANT IMPROVEMENT
CENSUS CODE: LOT SIZE: _
ZONING DESIGNATION: BUILDING SHELL ONLY? o YES o NO
COMP PLAN DESIGNATION BASIC PLAN? 0 YES ❑ NO
SECTION TOWNSHIP RANGE NEW ADDRESS REQUIRED? o YES ❑ NO
PLATTED LOT? ❑ YES o NO CHANGE OF USE? o YES ❑ NO
COMMUNITY DEVELOPMENT SERVICES•33530 FIRST WAY SOUTH•PO BOX 9718•FEDERAL WAY,WA 98063-9718•253-661-4000•FAX:253-661-4129
www.citvoffedera Iway.corn