15-106464 A. 111
CITY OF PERM1TVPPLICATION
Federal Way
DEC 22 2015
QTY OF FEDERAL WAY
PERMIT NUMBER 5
- \ 0 Co Li („, ' - ICARaT DATE P 1 Pc
SITE ADDRESS SUITE/UNIT#
'3 Z o, t 32., AV CE 32_0
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ 1LA Z. r 5 Lt. 5 - 0c) [
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING 14 FIRE PREVENTION
NAME OF PROJECT 5 5 Q.{- + '
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PROJECT DESCRIPTION \\ ` ��
Detailed description of work to CA vA C4 t'Q 1 `ck c-c. ri ct W( n Q,l.�-)
be included on this permit only )
NAME i PRIMARY PHONE
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PROPERTY OWNER � I � � G � - �' � '�
MAILING ADDRESS C 0 \ A ',n A J E-MAIL
CITY \ STATE ZIP
4 C6
NAME PHONE
J
MAILADD G`� E-MAIL
LIMAILING
CONTRACTOR 1' �'k I C)
CITY STATE ZIP FAX
Iv 1v1vA\ c_t-C-L,k L'C, A �'39 2
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
C.7-C0`V=-c �) II / ) ) /2r4-;
NAMEPRIMARY PHONE
arle 15 C.)c›u i 5 el3 t= 31 z,
APPLICANT MAILING ADDRESS E-MAIL
1 I A-`` P 1 `J i.) C'h rI L�c„k-ra 1"cell 3�Z
CITY STATE ZIP FAX
1- : )e).
'� l3.'-N, `1`1S C 7
N PRIMARY PHONE
PROJECT CONTACT .Vv‘ L t1 1 kk�� 'I L.- r•Sc
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
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 Iaws 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 ari out of t,- re za e of the city, including its officers and employees, upon the accuracy of the
information supplied to the c' as pa is ap ication.
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SIGNATURE: / DATE t 4 ZZ l 7s--.31
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PRINT N11 ME: �✓"'�j'\ \ 1,'� Cpz,v i `J
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application
lo r
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(orTub/Shower combo) LAVS(Hand Sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER(Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS(xitchen/untity) 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 � �— —__---- — Y
Area Totals
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE$ #OF BEDROOMS
COMMERCIAL—NEW/ADDITION
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
in Square Feet Type Stories
NEW BUILDING
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
in Square Feet Type Stories
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100—January 1,2013 Page 2 of 3 k:\Handouts\Permit Application