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05-100521
# 0 . City of Federal Way Community Development Services Building - Single Family Permit #: 05 - 100521 - 00 - SF P.O.Box 9718 Federal Way,WA 98063-9718 Ph:(253)835-7000 Fax:(253)835-2609 Inspection request line: (253) 835-3050 Project Name: KOBETS Project Address: 30506 24TH AVE SW Parcel Number:889420 0060 Project Description: NEW-Construction of a new 5060 sqft,2-story residence with an attached 634 sqft garage and 473 sqft of decks,including plumbing& mechanical. ***4 bedrooms,proposed selling price: $600,000*** Owner Applicant Contractor Lender ALEX&ALINA KOBETS ALEX&ALINA KOBETS ALEX&ALINA KOBETS ALEX&ALINA KOBETS 11712 SE 268TH ST 11712 SE 268TH ST 11712 SE 268TH ST KENT WA 98030 KENT WA 98030 11712 SE 268TH ST KENT WA 98030 KENT WA 98030 Includes: Census category: 101 -New si #1 g n'• _I #2 i #3 #4 Occupancy Group: -11 R-3 U-1 — Construction Type: - _- Type V-N Type V-N 1 Occupancy Load: IF_ — Floor Area(Sq.Ft.): — 1st Floor Proposed Sq.Feet 2230 2nd Floor Proposed Sq.Feet 2830 Basic Plan No Census Category g 101-New single family houst Construction Type#2 Type V-N Deck Proposed Sq.Feet 473 Fire Sprinklers Required No Garage Proposed Sq.Feet 634 Height of Structure 26 Mechanical Occupancy Group#1 Yes R-3 Occupancy Group#2 U-1-I Plumbing Yes Zoning Designation RS 9.6 Plumbing Fixtures DescriptionQtaantity j Description _ P __ J(Quantity L Description Quantity; Bathtubs 3 Dishwashers 1 I Laundry Washer Outlets --5----1- , Lavatories 6 Other Plumbing Fixtures I 3 I Showers JI 1 ! Sinks 3 Water Closets J 4 I L Water Heaters 1 _i Mechanical Fixtures Description ri H. _ p i IQuantityi l Description quantity I Description 1IQuantityl Ducts I Fans 8 j rFireplace Inserts 3 I Furnaces —_ J 1 j Ranges + I CONDITIONS: This decision shall not waive compliance with future City of Federal Way codes,policies,or standards relating to the subject proposal. t • r PERMIT EXPIRES August 27,2005. f Permit issued on February 28,2005 I hereby certify that the above information is correct and that the construction on the above described property and the occupancy and the use will be in accordance with the laws,rules and regulations of the State of Washington and the City of Federal Way. �) Owner or agent: ,'"f t/ Date: , 2 c_5-i City of Federal Way Certificate of Occupancy This Certificate issued pursuant to the requirements of Section 110.3 of the Uniform Building Code certifying that at the time of issuance,this structure was in compliance with the various ordinances of the City regulating building construction or use. This certificate is valid ONLY when endorsed by City staff. Tenant Name: KOBETS Permit number: 05 - 100521 -00 Address: 30506 24TH SW #1 #2 #3 #4 Occupancy Group: R-3 Construction Type: Type V-N Type V N Occupancy Load: - — _I--- — J - Floor Area(Sq.FL): _ ---H- F– Owner ALEX&ALINA KOBETS Name: 11712 SE 268TH ST Address: KENT WA 98030 Xc 8° b.-- (>4t Kai 0 CP Building Official Da e The priority focus in the review and inspection made by the City prior to issuance of this Certificate was on those matters which experience has shown most severely affect the health and safety of the general public. Although the City has made as complete a review and inspection as is reasonably possible(within budgetary time and personnel limitations),the City neither guarantees nor warrants to the owner/occupant or to any other person that this Certificate evidences strict compliance with each and every ordinance or regulation of the City or the State of Washington affecting the construction or use of said structure or the land upon which it is situated. Such compliance is the responsibility of the owner and/or occupant of the premises. IE G INSPECTORS AREA AND TYPE 0 NSPECTION ? 42410,r ! Fo ri,U c/A/..✓®v s.�o:.:; �,✓ �i-L- z o,,,r,� /6si-i ' i.rIc-r n- ,?-/f2 et' .9.7.10 �t�i✓✓7J�zy-7vry //Cei 777 : TI'3IS CARL?IS TWMAIN ON-SITE CITY OF .'" • ,• Community Development Inspection Record Federal Way IVR INSPECTION REQUEST PHONE # (253) 835-3050 PERMIT #: 05-100521-00-SF Owner: ALEX & ALINA KOBETS Address: 30506 24TH AVE SW FEDERAL WAY, WA 98023 This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD. Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence. On-going inspections are logged on the back of this card. 0 Temp.Erosion Control (4365) M Footings/Setback(4110) 0 Foundation Wall (4115) To be done prior to breaking ground ^ Approved to place concrete � ApprovedApto place concrete By '? /(i Date 3 D.� ByCy1 Date 3IIOD� By !Ge.--ppDate .3A742--- 0 Drainage/Downspout(4040) �❑ Plumbing Groundwork(4190) 0 Slab/Concrete Floor(4255) Approved to backfill07/6r Approved to cover Approved to place concrete • By ,� Date By Date � By Date • ❑ Underfloor Framing(4285) 0 Floor Sheathing(4105) 0 Shear Walls (4245) Approved to sheath floor Approved to install flooring Approved to install siding B \,11M1 Date 4 Qs.- By fry- Date $1– By 4_03Date 6 - (-O IDRoof Sheathing (4220) I❑ Rough Plumbing(4230) 0 Mechanical Rough-in (4165) Approv:d to install roofing Approved Approved By C J Date S Za. ,,Qs.--By ( ---' Date ?i Oc By G J Date7. (8 • �. , ❑ Gas Piping (4125) 0 Fire/Draft Stops (4095) s NOTE: Prior to scheduling a Framing(4120) Approved to release test pproved inspection;Electrical,Plumbing&Mechanical Rough-in and Fire/Draft Stop inspections must be ' ned-off and approved. IBC 109.3.4/UBC 108.5.4 By L Date- _d By G Date / - as _ ,, • e❑ Framing(4120) ❑ Insulation (4150) 0 Gypsum Wallboard Nailing(4130) Ap oved to insulate Approved to install wallboard Approved to install mud&tape By G Date --9By Date 9 e ar By Date 7/2.Y' ,❑ Final-SWM(4375) ❑ Final-Mechanical(4065) ❑ Final-Plumbing (4075) Approved Approved Approved By Date By Date By Date ►.1 Final-Building(4050) ['Temp. Erosion Maintenance(4370) Approved Approved a. By TM Date % % , I ,,,,, By Date Rug 15 2006 10: 48RM CARPET PLUS LLC 2068383930 p. 1 Assciated Earth Sciences, 1 1. Cegra6 y25 Z/eat ofService August 10, 2006 Project No, KE060561A Mr. Alex Kobets 11712 SE 268th Street Kent, Washington 98030 Subject: Segmental Retaining Wall Stability Analysis Kobets Residence 30506 24th Avenue SW Federal Way, Washington Dear Mr. Kobets: At your request, Associated Earth Sciences, Inc. (AESI) has performed a stability analysis of the recently constructed segmental retaining wall at the above-referenced address. Our scope of work included visiting the site, assessing the as-built wall and soil conditions, and performing an analysis of the stability of the wall using generally accepted engineering methods for segmental retaining walls. Written authorization to proceed with this study was granted by Mr. Alex Kobets. Our study was based on our visit to the site and accomplished in general accordance with our scope of work letter dated August 4, 2006. This letter has been prepared for the exclusive use of Mr. Kobets and his agents for specific application to this project. Within the limitations of scope, schedule, and budget, our services have been performed in accordance with generally accepted geotechnical engineering and engineering geology practices in effect in this area at the time our report was prepared. No other warranty, express or implied, is made. SITE OBSERVATIONS AND UNDERSTANDING An AESI engineer visited the site on August 1, 2006 to document site conditions. We observed that the segmental retaining wall construction had been completed prior to our arrival. The wall was located in the backyard of the residence and was apparently used to retain fill soil necessary to create a flat lawn area between the wall and the house. We understand that the blocks are "Diamond" blocks (by Anchor Retaining Wall Systems), which we measured to be approximately 16 inches wide (along wall face), 12 inches deep, and 6 inches thick. The blocks had a tri-pane rough face and an approximately 1'h-inch-wide offset notch at the bottom back of the block. We observed that the wall was 8 blocks high for a total wall height of 4 feet, with the bottom block buried. The ground surface at the toe of the wall Kiridand office•911 Fifth Avenue,Suite 100•Kirkland,WA 98033•P (425)827-7701•F+(425)827-5424 Everett Office•2911 1/2 Hewitt Avenue,Suite 2•Everett,WA 98201•P I(425)259-0522•F I(425)252-3408 ww vaesgeo com Aug 15 2006 10: 48AM CARPET PLUS LLC 2068383930 p. 2 • 1110 sloped down to the east at an approximate inclination of 2H:1V (Horizontal:Vertical) for approximately 14 feet. A wooden fence was located at the bottom of the slope that abutted the backyard lawn area of the adjacent residential property. The ground surface above the wall was predominantly level with the top of the wall with an undulating landscaping mound of topsoil approximately 1 foot high on the east edge of the lawn area. No structures were observed within close proximity to the wall that are sufficient to add surcharge loads. We understand that the wall was also tied back to the soil with steel anchors bolted to the back of blocks three to four blocks down from the top with horizontal spacings ranging from approximately 4 to 8 feet along the back of the wall. We understand that the closer spacings were near the ends of the wall where the wall curved back toward the house. We also understand that the anchors are approximately 10 to 15 feet long and the ends that are away from the wall were secured to the ground with steel stakes. We were informed that the wall contractor had installed these anchors to provide an extra measure of stability for the wall. While on-site, we observed removal of the top few blocks from the center section of the wall to confirm two anchor points on the third block down, approximately 141/ feet apart. We understand that there is an anchor between these, but the anchor points were staggered on the third and fourth blocks down from the top. The steel anchor consisted of a channel-shaped, steel strip with a width of approximately 3 inches. We also observed a hand-dug excavation approximately 8 feet behind the wall to confirm the length of the steel anchor. We observed the steel anchor, which extended past the excavation confirming a length of at least 8 feet. We probed the soil in the excavation during the excavation process with a 1/2-inch-diameter steel probe and penetrated 1 to 3 inches under the full weight of the observer. The backfill soil consisted of a moist, medium dense, brown sand with few to little silt and gravel that appeared to be well compacted. The removal of the top few blocks in the center portion of the wall revealed the non-woven filter fabric near the back of the blocks segregating the rounded gravel drainrock from the backfill soils. We understand that there is a perforated pipe footing drain at the bottom of the wall, but we were unable to confirm this without dismantling of the wall. We took photographs of the wall, blocks, and exposed anchors for documentation purposes. The photographs are on file in our office and are available for review upon request. CONCLUSIONS AND RECOMMENDATIONS We analyzed the as-built dimensions and estimated soil properties of the segmental block retaining wall using SRWa11 Version 3.22 software by the National Concrete Masonry Association (NCMA). Although steel strips and rebar are often used in mechanically stabilized earth applications, the steel channel anchors observed are not typical reinforcement and are difficult to model with their steel stake tiedowns. Therefore, we have neglected the steel reinforcement and modeled the wall as a gravity retaining structure. 2 Rug 15 2005 10: 48AM CARPET PLUS LLC 2068383930 p, 3 , The results of the analysis indicate that the wall meets the minimum factors of safety of 1.5 for direct sliding and overturning, and 2.5 for bearing capacity for static conditions, based on the observed geometry and estimated soil properties. The SRWa1I analysis summary with measured geometry and estimated soils properties is attached to this letter. In our opinion, the wall should be stable as a gravity retaining structure during static conditions and should be suitable for its use as a low height (i.e., 4 feet high or less), landscape retaining wall. The use of non-conventional steel anchors should provide additional resistance to overturning and direct sliding, although their benefit is difficult to quantify. It should be noted that we did not perform a seismic stability analysis due to the walls use for retaining landscape soils above a non-usable landscape area, which, in our opinion, carries a relatively low risk to public health and safety. Further, global slope stability analysis was not completed for the fill placed on the slope. However, no signs of instability were noted and, in our opinion, the risk of slope instability appears low. We recommend that no excavation take place on the slope below the wall, which may undermine support for the wall and backfill. We recommend that no structures be constructed or additional soil be placed within a 2H:IV line extending up from the base of the wall back towards the house, which may increase the driving forces on the wall. Furthermore, care should be taken not to oversaturate the backfill soil due to overwatering, and broken/leaky pipes should be repaired immediately. The owner should be aware that surcharges, excessive water in the retained soils, and strong ground shaking from earthquakes may cause damage to the wall. CLOSURE We hope this information meets your present needs. If you have any questions concerning this letter, please feel free to contact this office. Sincerely, ASSOCIATED EARTH SCIENCES, INC. o,wascs rjO Kirkland, Washington •'c . 0h '. Agog 1 0 t Le.c...9 8A•,7 2.0c.,C.- atm ONAL �EXPfRES 2/27/7-c07- , Eric J. Lim P. ' . G. Aaron McMichael, P.E., P.E.G. Project Engineer Associate Engineer Attachment: SRWaII Analysis Summary EILtts-KE060561A2-Projects12OO6o561 \WP 3 Aug 15 2006 10: 48AM CARPET PLUS LLC 2068383930 p. 4 410 SRWa11 (ver 3. 22 April 2002) Page 1 LN 0510893 Licensed to: Tim Peter Associated Earth Sciences 911 5th Ave #100 Kirklan WA 98033 License Number: 0510893 Project Identification: Project Name: Kobets Wall Section: As-Built Data Sheet: Owner: Alex Kobets Client: Alex Kobets Prepared by: Bim, Date: 8/9/06 Time: Data file: z:\projects\060561 kobets wall analysis\ke060561a diamond Type of Structure: Gravity Segmental Retaining Wall Design Methodology: NCMA Method 5E7 tC Seismic Analysis Details: I2 6-0 tAJ L-/}-0,4),SG S. Gt14-S Peak Ground Acceleration (PGA) ratio 0.00 Wall Geometry: - 61-OCT-- Design 2?,U cC_TDesign Wall Height (ft) 4.0 Embedment Wall Height (ft) 0.5 Exposed Design Wall Height (ft) 3.5 Minimum Levelling Pad Thickness (ft) 0.5 Number of Segmental Wall Units 8 Hinge Height (in plane of wall) (ft) N/A Wall Inclination (degrees) 10.6 Aug 15 2006 10: 48AM CARPET PLUS LLC 2068383930 p. 5 • SRWa11 (ver 3. 22 April 2002) Page 2 LN 0510893 Slopes: Front Slope (degrees) 26.0 Back Slope (degrees) 18.0 Distance to Broken Back (ft) 2.0 Equivalent Back Slope (degrees) 4.64 Uniformly Distributed Surcharges: Live Load Surcharge none Dead Load Surcharge none Friction Cohesion Angle Unit Weight Soil Data: Soil Description: (psf) (degrees) (pcf) Retained Soil SAND w/few to little silt and gravel N/A 35.0 130.0 Levelling Pad Soil gravel N/A 40.0 130.0 Foundation Soil SAND w/few to little silt and gravel 0.0 35.0 130.0 Segmental Unit Name: Diamond Segmental Unit Data: Cap Height (in) none Unit Height (Hu) (in) 6.0 Unit Width (Wu) (in) 12.0 Unit Length (in) 16.0 Setback (in) 1.125 Weight (infilled) (lbs) 80.0 Unit Weight (infill®d) (pcf) 120.0 Center of Gravity (in) 6.0 Segmental Unit Interface Shear Data: 0AA-N0-4-774-) Properties Ultimate Strength Criteria Service State Criteria Minimum (lbs/ft) 1076.0 770.0 Friction Angle (degrees) 26.0 23.0 Maximum (lbs/ft) 2150.0 2050.0 Aug 15 2006 10: 48AM CARPET PLUS LLC 2068383930 p. 6 SRtaa11 (ver 3. 22 April 2002) Page 3 LN 0510893 coefficients of Earth Pressure and Failure Plane Orientations: Retained Soil (Ka) 0.185 Retained Soil (Ka horizontal component) 0.181 Orientation of failure plane from horizontal (degrees) 54.27 Results of External Stability Analyses: Calculated D-sign Crite FOS Sliding 1.54110. fp „..__ FOS Overturning 1.59 K OK �1� FOS Bearing Capacity 18.05 2.5 OK Base Footing Width (Bf) (ft) 1.5 N/A Base Eccentricity (e) (ft) 0.19 N/A Base Eccentricity Ratio (e/Bf') 0.17 N/A Note: design criterion EXCEEDED (1 occurrences) Detailed Results of External Stability Analyses: Calculated Values: Total Horizontal Force (lbs/ft) 188.1 Total Vertical Force (lbs/ft) 480.0 Sliding Resistance (lbs/ft) 281.9 Driving Moment (lbs-ft/ft) 250.8 Resisting Moment (lbs-ft/ft) 397.5 Bearing Capacity (psf) 7797.8 Maximum Bearing Pressure (psf) 431.9 Results of Facing Stability Analyses: SRW Heel Geosynthetic FOS FOS Unit E1ev Type Over- Sheer # (ft) turning (peak) > 1.5 > 1.5 8 3.5 none 61.25 >99 7 3.0 none 16.75 96.51 6 2.5 none 8.08 44.0 5 2.0 none 4.9 25.37 4 1.5 none 3.37 16.64 3 1.0 none 2.5 11.83 2 0.5 none 1.95 41. : 1 0.0 none 1.59 ©1 Note: * value does NOT MEET design criteri. (1 occurrences) Aug 15 2006 10: 49AM CARPET PLUS LLC 2068383930 p. 7 SRWa11 (ver 3. 22 April 2002) Page 4 IN 0$10893 Detailed Results of Facing Stability Analyses (Moment and Shear): SRW Heel Geo Drive Resist Shear Shear Unit Elev Type Moment Moment Load Capacity 0 (ft) (lbs-ft/ft) (lbs-ft/ft) (lbs/ft) (lbs/ft) (peak) 8 3.5 none 0.5 30.0 2.9 1105.3 7 3.0 none 3.9 65.6 11.8 1134.5 6 2.5 none 13.2 106.9 26.4 1163.8 5 2.0 none 31.3 153.8 47.0 1193.1 4 1.5 none 61.2 206.3 73.5 1222.3 3 1.0 none 105.8 264.4 105.8 1251.6 2 0.5 none 168.0 328.1 144.0 1280.8 1 0.0 none 250.8 397.5 188.1 281.9 Aug 15 2006 10: 49AM CARPET PLUS LLC 2068383930 p. 8 410 SRWalI (ver 3.22 April 2002) Page 5 LN 0510893 2. 0 ft 10.6 degrees H 1 9 .0 ft % --- - ---- -�—_�_ --- 0.5 ft A_ -0.5 ft Project Identification: Project Name: Kobets Wall Section: As-Built Data Sheet: Owner: Alex Kobets Client : Alex Kobets Prepared by: EJL Date: 8/9/06 Time: Data file: z: \projects\060561 kobets wall analysis\ke060561a diamond CITY OF` — f 0 0 5 a_ FederalRECEI - _ F,RMIT - - - - ' COMMUNITY DEVELOPMENT SERVICES O MF CO ME EL PL DE EN FP 33325 8T"AVENUE SOU771•PO BOX 9718 FEBO 253 835-2-2607•FAX 253835-2609 B O APPLICATION - N •. www.ci tyoffederal way.com CITY OF FEDERAL WAY �_�I The ollowjn. is re.uired inOrnidtidrt-'&rl i •,om.lete a..lication will not be acce.ted. Please .rint .z hIl PROPERTY INFORMATION •r •e. SITE ADDRESS 3 0506 24/ 4k ' S i; FE OE/9091. I./4 y SUITE/UNIT# 19 ASSESSOR'S TAX/PARCEL# 8 ' t' Ali /2 0 -� 0 0 6 Q LOT SIZE(sf) 99 9 3 y ,' LEGAL DESCRIPTION (e.g.Acme Estates,Lot 1) LO'hp V teach separate page{/lengthy legal descaption) : .., r PROJECT INFORMATION TYPE OF PERMIT ]BUILDING 2LUMBING MECHANICAL �❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING ❑ FIRE PREVENTION SYSTEM PROJEC5 DESCRIPTION (Provide detailed description of work included on this permit only) 1 x ) '1 " I i° .‘k 6c...,,, . ,' ' Nil ` p1_, - c S , cLa � pea. ^ , L' 4 ! 4 . PROJECT NAME(Name of Business or Owner Last Name) ,,<O6 C-..--S" • _. L! PEOPLE INFORMATION PROPERTY NAME PRIMARY PHONE OWNER Ak E,r !c c7/3 t=i S (253163o -/323 MAILING ADDRESS CITY,STATE,ZIP I/ 3/2 ss 268 Sr kEh/ 1-49 ` eo30 CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE OW lq)F 4LGX Xpa:rs' (206 )e38 -1399. MAILING ADDRESS CITY,STATE,ZIP CELL PHONE CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER EXPIRATION DATE (20Z1.22 FAX NUMBER 220 / — — — B L / ' (2o6 ) eZc4 393o CONTRACTOR'S REGISTRATION NUMBER(copy of card required with each application) EXPIRATION DATE / APPLICANT COMPANY NAME APPLICANT NAME OFFI PHONE d (k)/JE/R—. /JLeX• ic0/3EiS ( ) - MAILING ADDRESS CITY,STATE,ZIP — CELL PHONE RELATIONSHIP TO PROJECT FAX NUMB ER ❑ Architect ❑ Tenant o Agent 0 Other(Describe) ( ) - CONTACT NAME PRIMARY PHONE E-MAIL ADDRESS /41c-yr ee04C---7'S (.253) 630 -432 3 LENDER Per RCW 19.27.095: Lender information is NAME required if project value exceeds$5,000 13 LE x k. 4e£ 7s.- MAILING ADDRESS CITY,STATE,ZIP 2 93 0 / 44E S SEAt/iF Vg J8/.34/ . •. • .• L. DETAILED BUILDING INFORMATION EXISTING USE Vaarrt PROPOSED USE VPS id-en C t --- EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $ C)L c) SPRINKLERED BUILDING? 0 YES ,R,NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? ❑ YES o NO WATER SERVICE PROVIDER ❑ LAKEHAVEN 0 HIGHLINE ,TACOMA 0 PRIVATE(WELL) SEWER SERVICE PROVIDER )<LAKEHAVEN ❑ HIGHLINE 0 PRIVATE(SEPTIC) 4)011 ari 0/4 r37-$/z, 36D - .03 -Z7(O Corn 1Ndit 40\er,°, - PROJECT FLOOR AREAS ._......._.... AREA D r i • ION EXISTING PROPOSED TOTAL S 0.FT. S..FT. S•.FT. (IIBASEMENT FIRST w.441 ---- ZZ 2270 SECOND28 0 "- THIRD "/:0(.2 FOURTH ADDITIONAL FLOORS(DESCRIBE) DECK(COVERS .) '1 1 413 GARAGE CARPORT❑ -- G 5 4- Gs EXISTING PROPOSED TOTAL TOTAL EXISTING SF TOTAL PROPOSED ST TOTAL SF NUMBER OF FLOORS " i **NEW HOMES ONLY" NUMBER OF BEDROOM'', 4.__ ESTIMATED SELLING PRICE $ i I r I I 411 FIXTURES. • Indicate number of each type of ixture to be installed lr r- ecated as part of this project. Do not include existing fixtures to remain. MECHANICAL ____D Value o MechanicalWor $ i0000 ,/� ...- AIR HANDLING UNITS (/ EVAPORATIVE COOLERS GAS LOGS -- ...... REFRIG.SYSTEMS 0 BBQS g FANS -d' HOODS)commercial) WOODSTOVES _____1_ BOILERS 3 FIREPLACE INSERTS ( RANGES MISC(Describe) PRESSORS URNA( ES / GAS WATER HEATERS DUCTS AS PIPE OUTLETS PLUMBING dillc BATHTAS)orT y et ) SHOWERS �g WATER CLOSETS(rout) MISC(Describe) DISHWASHERS SINKS DRINKING FOUNTAINS GAS PIPE OUTLETS SUMPS ALS/ RAINWATER SYST I WASHING MACHINES URINALS �43 HOSE BIBBS LAVS(Bathroom sinks) VACUUM BREAKERS pp ELECTRIC WATER HEATERS • DIS_CLAIM_ER/SIGNATURE BLOCK Icertify under penalty of perjury that the in i rmation 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. ,/� G . 44.6" ii/fre e DATE J2. 6 9 03 am NAME/TITLE �' �O�Cr�' O (Signature) (Title) RELATIONSHIP TO PROJECT p(Owner 0 Agent a Contractor ❑ Architect 0 Other FOR OFFICE USE ONLY ❑NEW ❑ADDITION ❑ALTERATION o REPAIR ❑TENANT IMPROVEMENT BUILDING SHELL ONLY? o YES ❑NO BASIC PLAN? ❑YES ❑NO ZONING DESIGNATION CHANGE OF USE? ❑YES o NO NEW ADDRESS REQUIRED? ❑YES ❑NO UP/SEPA/SU? o YES ❑NO PLATTED LOT? n YES ❑NO DEMO PERMIT REQUIRED? a YES a NO I i Bulletin#100—January 7,2005 Page 2 of 4 k\llandouts\Permit Application