13-106112On of A�
Federal Way
PERMIT NUMBER / - _
APR 12 V13
CTC`( OF FEDSR`LWAY
ivi%io2—,
73C)C,
PERM IT*APPLICATION
TARGET DATE ( ��
SITES ADDRESS
SUITE/UNIT #
PROJECT VALUATION
$ /S -u -ac)
ZONING
ks T,
I ASSESSOR'S TAR/PARCEL #
03 g 6 U b_ 00 6
TYPE OF PERMIT
bl,UILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
e - / S1,to
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
'p- yu�r t, o r ,
f4
PROPERTY OWNER
NAME G
�,�,'�✓
PRIMARY PHONE
�j °j�3'% "���:�
NAMING ADDREU y���-�
E-MAu,
CITY
STA
ZIP FOB 0-23
NAME
e
PHONE
NAMING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
NAMING ADD
mss- 6 :Stj
E-MAIL
APPLICANT
_
ST�� � ��
FAX
PROJECT CONTACT
NAME
PRIMARY PHONE
MAILING ADDRESS
EMAIL
(The individual to receive and
respond to all correspondence
CITY STATE ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER-FDFANCED
Required value of $5,000 or more
(RCW 19.29.095)
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 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 ci o this application.
SIGNATURE: DATE / a Cy' r J
PRINT NAME: G 4 rY
Bulletin 4 100 -January 1, 2013 Pagel of 3 k:\Handouts\Permit Application
GENERAL,KFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYORPURVEYOR
VALUE OF EXISTING IMPROVEMENTS
tjo
pa�(
EXISTING/PgKVIOUS USE
LOT SIZE (Ia Square Feet)
S41
EXISTING FIRE SPRINKL SYSTEM?
f3Yes ❑
PROPOSED FIR SUPPRESSION SYSTEM?
❑ Yes N --'No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
,� �:.
FIRST FLOOR (or Mobile Homy
COVERED ENTRY
GARAGE ❑ CARPORT ❑
Area Totals / I IXWMa I P I — I -- 1
COMMER"CIAL — NEW/ADDITION
AREA DESCRIPTION Area Occupancy Group(s) Construction Stories Additional Information
in Square Feet
ADDITION
COMMERCIAL — REMODEL/TENANT IMPROVEMENTS
Area Construction # of
AREA DESCRIPTION Occupancy Group(s) Additional Information
in Square Feet Type I Stories
TENANT AREA ONLY
Bulletin # 100 — January 1, 2013 Page 2 of 3 Uflandouts\Pennit Application