12-105042 r _ ( 0 5 01-2
MY OF RECEIVED •PERMIT F CO ME PL DE EN6:1--)3
Federal Way' 6
yylI 11��/' /ry
COMMUNITY DEVELOPMENT SEIZVJ ES' 0 5 2012A P P L I C A T I 0 N
253-835-2607•FAX 253-835-2609
"i1'°f`{1F:-r'' Y OF FEDERAL WAY
CDS
SITE ADDRESS ' Z J/-�r`/ 3co
to 3p '`2S E T#
#A_
PROJECT VALUATIODr. ZONING ASSESSOR'S TAX/PARCEL#
$ 250 .E ZSZI 03 - q0 I
TYPE OF PERMIT ElBUILDING LIPLUMBING CIMECHANICAL
El DEMOLITION El ENGINEERING
N FIRE PREVENTION
NAME OF PROJECT
"
(Tenant Name/Homeowner Last Name) 5# /iota thel1
'�� co- chj
1L 01jor 0 h
PROJECT DESCRIPTION
Detailed description of work to Ae/r ( )re 01 /W rP 5 )Qt\
be included on this permit only /
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
r — NAME /'0 t / liMfl A f /1 PHONE
MAI DRES {/Y'nl l E-MAIL
CONTRACTOR II ur ck.r ,-- )-het _
CITY '�� �� STATE ZIPb4 1,ffte in � FAX
WA STATE CONTRACTOR'S� IC NSE { EXPIRATION DAT a FEDERAL WAY BUSINESS LICENSE#
��MiltA '' 66iL/ to / 5 / / '
NAMEPHONE
i \Vk1i
fail/ J
APPLICANT MAILING /I 1 /fig r��QJ E-MAIL
CITY Tq, )/iSTAT ZIP (. 1l L FAX
PROJECT CONTACT NAME94/W/j` ',l 4� A STA
/ 6T a 7 PHONE
(The individual to receive and ci'_t I
respond to all correspondence MAILING ADDRESS{'—CI I i 0+f g . . ] �� i r E-MAIL
concerning this application) v "I V �j �` V
•
CITY .( r)14 1 k STATE ZIP /7I Jt„6 FAX
ALTERNATE CONTACT NAME: q�•/, PHONEV/ylf•7/ E-MAIL
Z -a o
PROJECT FINANCING NAME ) tt q, peo.
j j 'NI OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,7 ATE,ZIP( / 3#5-611, n 5� 7-S 3 PHONE
6e, '3736
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.
� 1(—c 261 Z
/
SIGNATURE: r'j� DATE
PRINT NAME: ill`I 'iv/1 ) 5 (C11 S
Bulletin#100—January 1,2011 Page 1 of 3 k:AHandouts\Perrnit Application
110
VALUE OF MECHANICAL WORK $ (a copyas ofpartbidof orthis estimate must povid/
Indicate how many of each type of fixture to be installed or project.
AIR HANDLING UNITS
Do be not includerdeexisting fixtures to remain.
FANS GAS PIPE OUTLETS relocated OTHER(Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS)commem;aq
BOILERS FURNACES HOT WATER TANKS)Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate how many of each type of jLrture to be installed or relocated as part of this project. Do not include existing fxtures to remain.
BATHTUBS(or rub/sho�rcombo) LAVS)IlaDas.a�s) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER(Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS(Kitchen/Utility) WATER HEATERS(El«trt)
HOSE BIBBS SUMPS WASHING MACHINES TOTAL F] TURLS
1,17
IIS' y� a.. r °_ , •
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 UNo
>''... K. e » ,, .L�c. .a va> .• W
AREA DESCRIPTION(in square feet) ING
PROPOSED TOTAL FOR OFFICE USE
EXIST
FIRST FLOOR(or Mobile Home)
COVERED ENTRY
GARAGE ❑ CARPORT ❑
43:4141.4. 94-1-40� '�
EXISTING PROPOSED TOTAL
Area Totals
� .r,, it A; - mil
ESTIMATED SELLING PRICE$ # OF BEDROOMS
AREA DESCRIPTION Occupancy Group(s) Constru• ction St res Additional Information
1/1111011
ADDITION
Nt—
AREA DESCRIPTION Occupancy Group(s) Constru• ction Stories Additional Information
TENANT AREA ONLY —.
PROJECT -• s
n'AREA
RAONL7a
Bulletin#100–January I,2011 Page 2 of 3 k:Aflandouts\Permit Application