16-102847 A. IV CD PERMITeiPPLICATION
CITY OF
Federal Way juN 09 zols
F ` • WA`s r
PERMIT NUMBER (
`! ) _ I
�` L� D m JJ--" }
_ _ TARGET DATE
SITE ADDRESS ' �® SUITE/UNIT#
S
p
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ , oo 0_ .1 Z / 0 y - q
/ 6
TYPE OF PERMIT tNG ❑ PLUMBING 0 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT tfc_Y1 ( V - �/� j\ )
PROJECT DESCRIPTION
Detailed description of work to I, - q \--e-,
I N W\
be included on this permit only
NAME I PRIMARY PHONE
PROPERTY OWNER ��i_ i 1 — ✓ �" '�L/�{-Imo 1
MAILING ADDRE I E-MAIL
CITY 1 STATE ZIP
•
. NAMF� 6-5[l V`) PHONE dA
Ir 35-7-0v-3 0
MAILING ADDRESS E-MAIL
CONTRACTOR Po "`°}X 260
CITY 1i(Ct bb Q.- STATE ZIP z FAX
t V �j�r' J
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
/ /
NAME 1 ___ ___11, T.,_} ;(--2 1 Q PRIMARY PHONE
APPLICANT i ,, . ADDRE E-MAIL
i► tric 12--:c
CI. 4WTAT
ZIP _ FAX
4E1 \Ck" 1442—e3 0-4 '7I 3-5 S
NAME ('� PRIMARY PHONE
PROJECT CONTACT 12--)r)4= ' Y L t (2 KV
(The individual to receive and MAILING DRESS ,Tn E-MAIL
respond to all correspondence ] -``_-)1 [---
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
When value is$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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 environ ental laws.
I further agree t• of• • less the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in
the investigation •nd def -e of such claim), which may be made by any person,including the undersigned,and filed against the city,
but only where - ch clai arises out f the rel ance of the city, including its officers and employees, upon the accuracy of the
information sup•lied
��tot -city ••p• of tit' 1,plication.
SIGNATURE r I_\_'_ I ` , I DATE A/Vp
PRINT NAME. 1! A• eci12---Tc-NA)
Bulletin#100—February 22,2016 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
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/utdity) 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 0
OTHER(describe)
EXISTING PROPOSED TOTAL
Area Totals
**MEW H011iES ONLY**
ESTIMATED SELLING PRICE$ #OF BEDROOMS
COMMERCIAL—NEW/ADDITION
AREA DESCRIPTION Area m Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
NEW BUILDING
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—February 22,2016 Page 2 of 2 k:\Handouts\Permit Application