14-104546v CITYOF PERMIT APPTTION
Federal Way
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PERMIT NUMBER _ � ® 4 � \ _ 00SEP 05 2014�+� N ®C FEDERAL WAY TARGET DZI 1 I I Rt\ YY
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SITE ADDRESSSUITE/UNIT
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#
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2&0 5 32Q"',-�)
A-10
PRO UATION��
ZONING
ASSESSOR'S 'TAX/PARCEL 57 0— 00
:J— 0
1 1
TYPE OF PERMIT
❑ BUILDING 1:1 PLUMBING MECHANICAL 11 DEMOLITION El ENGINEERING )FIRE/PREVENTION
NAME OF PROJECT
22
PROJECT DESCRIPTION
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Detailed description of work to
/
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY STATE
ZIP
N
PHONE
�LIND�RiS
t
E-MAIL -
CONTRACTOR
C Y •
STAT
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I � _ � _
W ATE CO T R'IS LICENNSE #
DAT$f.
FEDERAL WAY BUSINESS LICENSE #
=-A
NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
NAME
--P# Y H
PROJECT CONTACT
DA
—
(The individual to receive and
MAILING ADDRESS
C -
MAIL % _
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
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 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 he city as a part of this application.
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SIGNATURE: DATE
PRINT NAME:
Bulletin #100 — January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
Z7
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT
Indicate how many of each type offixture to be installed or relocated as part of this jorgiect. 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
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
VALUE OF PLUMBING WORK
PLUMBING PERMIT
# of
Stories
Additional Information
NEW BUILDING
EXISTING/ PREVIOUS USE
LOT SIZE (In Square Feet)
$
Indicate how many of each !Yee offixture
to be installed or relocated as
part of this project. Do not include existing fixtures to remain.
BATHTUBS (or Tub/ Sho rCombo(
LAVS (Hand Sinks)
TOILETS
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
TOTAL BUILDING
DRINKING FOUNTAINS
SINKS (Kitchen/Utility(
WATER HEATERS (E(eccric(
HOSE BIBBS
SUMPS
WASHING MACHINES
TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
# of
Stories
Additional Information
NEW BUILDING
EXISTING/ PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
ADDITION
❑ Yes ❑ No
❑ Yes ❑ No
RESIDENTIAL - NEw OR ADDITION
AREA DESCRIPTION (in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
............... .................. ...... ..._.............. .................... _.............. .................................... __......
BASEMENT
.............. ........................... .......................................................... _........ .. _............. _..................................... I ...........
..
FIRST FLOOR (or Mobile Home)
............................................................................................................................................................................................
SECOND FLOOR
COVERED ENTRY
............................................................................................................... . ..................... . ......................... .. _.....
DECK
GARAGE ❑ CARPORT ❑
................. .........._................. ................................................. .................................................... .............. _....
OTHER (describe)
........................... .................................................................. ................
Area Totals EXISTING PROPOSED TOTAL
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE $ 1 # OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
# of
Stories
Additional Information
NEW BUILDING
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
# of
Stories
Additional Information
TOTAL BUILDING
'.
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin #100 — January 1, 2013 Page 2 of 3 k:\Handouts\Permit Application
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