12-103055 7. - C)3 0
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Federal waECEIVED
COMMUNITY DEVELOPMENT SERVICES 03 2012APPLICATION 4 -�
253-835-2607•FAX 253-835-26JU
www.d t goffedernlwaasos
CITY OF FEDERAL WAY
SITE ADDRESS CDS SUITE/UNIT#
( e G50 3�F�r� ST wktil w A 9 -5
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING ElMECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) C
PROJECT DESCRIPTION J v�N Ek*,�_ ?AA OUT FOP- St AA t -A 2_ P
Detailed description of work to \1<e �-••O C_.CE.. )
be included on this permit only
NAME PRIMARY PHONE Q p 6
PROPERTY OWNER S O'PV Q— i i1 xt:x„ YV\-(0/ Cr) S 3-53 3$
MAILING ADDRESS E-MAIL
1647 SCUTA. 3�b Sj
CITY STATE ZIP _
De Q1(L, U' j Cc 6V6,00
S
NAME PHONE
�"ti-- C_ 'Lc
MAILING ADDRESS E-MAIL
CONTRACTOR SZO2 OU-t'V p L q��L: C-ir kres\ue .c.
CI STATE ZIP FAX
lG 1 02 `25'3 psi -q-3-Sz
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
fA `3\ Z-tAC 3 e / 3. /b'-N,
NAME PHONE
1�A.1 --
APPLICANT MAILING ADDRESS P��/"V E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACT NAME PHONE
(The individual to receive and —
S �`{
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application)
CITY STATE ZIP FAX
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
OWNER-FINANCED
Required value of$5,000 or more
(RCW 19.27.095) Iv r MAILING ADDRESS,CITY,STATE,ZIP PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct.I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit.I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs, expenses, and attorneys'fees incurred in
the investigation and(I= ense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such i,im arises out o the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to he city as a pa of this application.
SIGNATURE: Al DATE i-13/a--
PRINT NAME: Akt$D{ 'i \012-eNi
Bulletin#100—January 1,2011 Page 1 of 3 k:\Handouts\Permit Application
• •
MEC:II_ NIC AL: FIXTURES ES .4
VALUE OF MECHANICAL WORK $ (a copy of bid or estimate must be provided)
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(Cotomercial)
BOILERS FURNACES HOT WATER TANKS(Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
• PI,L ivikwiG FIX.1"UR1 S
Indicate how many of each type of fixture to be installed or relocated as port 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/Utility) WATER HEATERS(Electric)
HOSE BIBBS SUMPS WASHING MACHINES TOTAI;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 ADDDITIOi'e
AREA DESCRIPTION (in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
BASEMENT
FIRST FLOOR(or Mobile Home)
SECOND FLOOR
COVERED ENTRY
GARAGE ❑ CARPORT ❑
OTHER(describe)
EXISTING PROPOSED TOTN. --------_------_--_-------__-----^�
Area Totals
**NEW HOMES ONLY**
ESTIMATED SELLING PRICE$ _ ___ #OF BEDROOMS
COMMERCIAL— NEW/ADDITION
AREA DESCRIPTION Area Construction #of
Occupancy Group(s) Additional Information
in Square Feet Type Stories
NEW BUILDING
ADDITION
COM1MERCIAL..—REZIODFLITENANT IMPROVEMENTS
Area Construction # of
AREA DESCRIPTION in Square Feet Occupancy Group(s) Type Stories Additional Information
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin#100-January 1,2011 Page 2 of 3 k:\Handouts\Permit Application