95-103314CITY OF FEDERAL WAY
33530 First Way South
Federal Way, WA 98003
661-4000
<BUILDING PERMIT ISSUED: 12/'1.9%95
Building Inspection Requests 661--4140
ADDRE:SS:629 S 331ST PL
NO.: 132140-0370
PROJECT DESCRIPTION:NSF N/PLUMBING AND MECHANICAL.
CAMPUS GLEN, LOT #37.
OWNER CONTRACTOR
CAMPUS GLEN LTD PARTNERSHIP POLYGON NW COMPANY
4030 LK WASH BLVD NE, 1201 4030 LK WASH BLVD WE
KIRKLAND WA 98033 SUITE #201
822-7700
KIRKLAND WA 9HU33
822-7700
POLYGNCU51D4
g5- /b3J� y
[a *Q101118100 -m
BY: KLC
EXPIRES: 1:2/19/97
RENEWED PERMIT
LENDER
SEATTLE MORTGAGE
229 QUEEN ANNE AVE N
SEATTLE WA 98109
g BLU?:X MEC?:X PLM?:X FLR- -EXIST- -PROP--- DWELLING UNITS: 1 COMP PLAN ......... :SR FEES:
TYPE OF WORK:NEW USEAES 1ST.: 0: 806:sf STORIES........: 2 REQUIRED PARKING..: 2 SPRINKLERS?......:? ? PLAN CHECK FEE $ 474.83
CENSUS CATEGORY ..... :101 2ND.: 0: 891:sf HEIGHT.....: O.11O ft HAZARD CLASS...:? PUB WKS PLCK(SF)..93 3 40.00
t OCCUPANCY GROUP---------- 3RD.: 0: O:sf VALUATION---------- I REQUIRED SETBACKS------- FIRE FLOW....: 0 9PI FINAL PLAN CHECK...* $ 0.00
:R3 :U1 :? :? OTHR: 0: O:sf EXIST..$: 0 FRONT.........: 20.00 fit BUILDING PERMIT....* 3 730.50
TYPE OF CONSTRUCTION----- BSMT: U: O:Sf PROP ... $: 125282 SIDE..........: 5.00 ft WATER SERVICE..:FED SBCC SURCHARGE.....* $ 4.50
:5N :5N :? :? DECK: 0: O:sf REAR..........: 5.00:ft SEWER SERVICE..:FEB NEC APPLIANCE FEES.* 3 60.50
OCCUPANT LOAD------------ GAR.: 0: 519:sf RECEIVED.: 12/05/95 PLUMBING FIXT.... 93* 98.00
0: 0: 0: 0: TOIL: 0: 2216:sf IMPERV SURFACE: 1925 sf SENSITIVE AREAS?.:N ; FINAL PLAN CHECK...* $ 50.00
ZRIILDING PERMIT....* $ 365.25
FUEL fYPES.:GAS ? FANS..........: 4 BOILERS/COMPRESSORS WATER CLOSETS......: 3 URINALS........: 0 TOTAL FEES 1 1823.58
GAS PIPING.: 0 ft HOOD..........: 1 0-3 HP......: 0BATR TUBS..........: 2 DRINKING FOUNT.: 0
FURN<100K..: 1 DUCT WORK.....: 0 3-15 HP.....: 0 1 SHOWERS ............: 2 SUMPS..........: 0 ,
GAS HWT....: 1 WOOD STOVES...: 0 15-30 HP....: 0 LAVATORIES.........: 4 VAC BREAKERS...: 0
CONY BURNER: 0 FURN)1OOK...... 0 30-50 HP..... 0 SINKS ............... 1 DRAINS.......... 0
BBQ......... 0 MISC........... 0 5+ HP........ 0 DISH WASHERS........ 1 LAWN SPRINKLERS: 0
GAS DRYER..: 1 AIR HANDLING UNITS FUEL TANKS--------- I ELIC MIR HEATERS...: 0 OTHER FIXTURES.: 0
RANGE......: 1 <:10,000 CFM: 0 ABOVE GROUND: 0 LAUN WSHR OUTLTS... : 1
GAS LOGS...: 1 > 10,000 CFM: 0
UNDERGROUND.: 0
PERMITS EXPIRE 180 DAYS AFTER ISSUANCE IF NO WORK IS STARTED_ RESIDENTIAL AND GRADING PERMITS EXPIRE ONE YEAR AFTER DATE OF ISSUANCE.
I CERTIFY THAT THE INFORMATION FURNISED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THE APPLICABLE CITY OF FERERAL WAY REQUIREMENTS WILL BE MET.
OWNER OR AGENT
DATE ...__ ..._ _...____.._
FILE COPY
ADDRESS:629 S 331ST PL
NO.: 132140--0370
PROJECT DESCRIPFI(ON.NSF W/PLUMBING AND MECHANICAL.
CAMPUS GLEN, LOT #37.
= OWNER CONTRACTOR LENDER
CAMPUS GLEN LTD PARTNERSHIP 1 POLYGON NW COMPANY I SEATTLE MORTGAGE
t 4030 LK WASH BLVD NE, #201 4030 LK WASH BLVD NE 1 229 QUEEN ANNE AVE N
KIRKLAND WA 98033 KIRKLAND WA 98033 SEATTLE WA 98109
822-7700 ( 822-7700 I
..__._- --• ��r�A��..-..____ ...___ ..._..�.._.. �__._._ POLYGNC051D4
*** CONTRACTORS, PLEASE USE LOCATION CODE 1732 WHEN REPORTING SALES TAX FOR PROJECTS WITHIN THE CITY OF FEDERAL WAY. TAX RATE : 8.2% ***
_-__. --�
BLD?:X MEC?:X PLM?:X FLR--EXIST--PROP--- DWELLING UNITS: 1 COMP PLAN ......... :SR FEES:
TYPE OF WORK:NEW USE:RES 1ST.: 0: 806:sf STORIES........: 2 REQUIRED PARKING..: 2 SPRINKLERS?......:? PLAN CHECK FEE $ 474.83
CENSUS CATEGORY ... ..:101 2ND.: 0: 891:sf HEIGHT.....: 0.00 ft HAZARD CLASS...:? PUB WKS PLCK(SF)..93 $ 40.00
OCCUPANCY GROUP---------- 3RD.: 0: O:sf VALUATION---------- REQUIRED SETBACKS------- FIRE FLOW....: 0 qpm FINAL PLAN CHECK...* $ 0.00
:R3 :Ul :? :? OTHR: 0: O:sf EXIST..$: 0 ! FRONT.........; 20.00 ft BUILDING PERMIT....* $ 730.50
TYPE OF CONSTRUCTION----- BSMT: O: O:sf PROP...$: 125282 SIDE..........: 5.00 ft WATER SERVICE..:FED SBCC SURCHARGE.....* $ 4.50
:5N :5N :? :? DECK: 0: O:sf REAR..........: 5.00:ft SEWER SERVICE..:FED MEC APPLIANCE FEES.* $ 60.50
OCCUPANT LOAD------------ GAR.: 0: 519:sf RECEIVED.:12/05/95 ? PLUMBING FIXT.... 93* $ 98.00
E
0: 0: 0: 0: TOTL: 0: 2216:sf IMPERV SURFACE: 1925 sf SENSITIVE AREAS?.:N
0 EL TYPES.:GAS ? FANS..........: 4 BOILERS/COMPRESSORS WATER CLOSETS .....;- 3� ` URINALS........: 0 ( TOTAL FEES $ 1408.33
S PIPING.: 0 ft HOOD........... 1 0-3 HP....... 0 BATH TUBS........... 2 DRINKING FOUNT.: 0
FURN<100K... 1 DUCT WORK...... 0 3-15 HP...... 0 SHOWERS ............. 2 SUMPS........... 0 q
GAS HWT.... : I WOOD STOVES...: 0 15-30 HP....: 0 LAVATORIES.........: 4 VAC BREAKERS...: 0
CONY BURNER: 0 FURN>100K.....: 0 30-50 HP....: 0 SINKS ..............: 1 DRAINS.........: 0
BBQ......... 0 MISC........... 0 5+ HP........ 0 DISH WASHERS........ 1 LAWN SPRINKLERS: 0
GAS DRYER..: 1 AIR HANDLING UNITS FUEL TANKS--------- r ELEC WTR HEATERS...: 0 OTHER FIXTURES.: 0
RANGE......: 1 <:10,000 CFM: 0 ABOVE GROUND: 0 LAUN WSHR OUTLTS...: 1
pp GAS LOGS...: 1 > 10,000 CFM: 0 UNDERGROUND.: 0 }1
L_._`--______.'_"_..__'_^_".cc;co-r_•nm.-_::_»_c=-c:^.c::.r.::., �aw�_........_.._�........_s.____y.___..M-,::_�._a-z:===^------""---'"-"•.....__---..________„..__............_......_......- cr.::"•� :�_;��_ .•ca�_oxcc�,s: x,^_�c::�-::r�^aor-� :::
PERMITS EXPIRE 180 DAYSAFTER ISSUANCE IF NO WORK IS STARTED. RESIDENTIAL AND GRADING PERMITS EXPIRE ONE YEAR AFTER DATE OF ISSUANCE.
I CERTIFY THAT THE NF TION F S ED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THE APPLICABLE CITY OF FEDERAL WAY REQUIREMENTS WILL BE MET.
OWNER OR AGENT DATE _ _-� _� (2--')a
G �.!U...---------------------._-..._--.._._-_.-_--____..._.__._._..._____...______... --------____�1_
FILE COPY
'CITY OF FEDERAL WAY
PERMIT N0:
BLD9S-0987
33530 F i r -s t Way South
.;;;1 h,„ ,aN .,,� ,.,,.•, .,�,.,.�' .,,�,,. I' �, '"ii �;;;;;u 11":;,. i � �'` }'h .,,��,. , �
ISSUED:
12/19/9
Federal Way, WA 95003
lkiiIdi.ng lnsper,t.ion RegUest::s 661-4140
BY:
KLC
661-4000
EXPIRES:
12/19/95
ADDRESS:629 S 331ST PL
NO.: 132140--0370
PROJECT DESCRIPFI(ON.NSF W/PLUMBING AND MECHANICAL.
CAMPUS GLEN, LOT #37.
= OWNER CONTRACTOR LENDER
CAMPUS GLEN LTD PARTNERSHIP 1 POLYGON NW COMPANY I SEATTLE MORTGAGE
t 4030 LK WASH BLVD NE, #201 4030 LK WASH BLVD NE 1 229 QUEEN ANNE AVE N
KIRKLAND WA 98033 KIRKLAND WA 98033 SEATTLE WA 98109
822-7700 ( 822-7700 I
..__._- --• ��r�A��..-..____ ...___ ..._..�.._.. �__._._ POLYGNC051D4
*** CONTRACTORS, PLEASE USE LOCATION CODE 1732 WHEN REPORTING SALES TAX FOR PROJECTS WITHIN THE CITY OF FEDERAL WAY. TAX RATE : 8.2% ***
_-__. --�
BLD?:X MEC?:X PLM?:X FLR--EXIST--PROP--- DWELLING UNITS: 1 COMP PLAN ......... :SR FEES:
TYPE OF WORK:NEW USE:RES 1ST.: 0: 806:sf STORIES........: 2 REQUIRED PARKING..: 2 SPRINKLERS?......:? PLAN CHECK FEE $ 474.83
CENSUS CATEGORY ... ..:101 2ND.: 0: 891:sf HEIGHT.....: 0.00 ft HAZARD CLASS...:? PUB WKS PLCK(SF)..93 $ 40.00
OCCUPANCY GROUP---------- 3RD.: 0: O:sf VALUATION---------- REQUIRED SETBACKS------- FIRE FLOW....: 0 qpm FINAL PLAN CHECK...* $ 0.00
:R3 :Ul :? :? OTHR: 0: O:sf EXIST..$: 0 ! FRONT.........; 20.00 ft BUILDING PERMIT....* $ 730.50
TYPE OF CONSTRUCTION----- BSMT: O: O:sf PROP...$: 125282 SIDE..........: 5.00 ft WATER SERVICE..:FED SBCC SURCHARGE.....* $ 4.50
:5N :5N :? :? DECK: 0: O:sf REAR..........: 5.00:ft SEWER SERVICE..:FED MEC APPLIANCE FEES.* $ 60.50
OCCUPANT LOAD------------ GAR.: 0: 519:sf RECEIVED.:12/05/95 ? PLUMBING FIXT.... 93* $ 98.00
E
0: 0: 0: 0: TOTL: 0: 2216:sf IMPERV SURFACE: 1925 sf SENSITIVE AREAS?.:N
0 EL TYPES.:GAS ? FANS..........: 4 BOILERS/COMPRESSORS WATER CLOSETS .....;- 3� ` URINALS........: 0 ( TOTAL FEES $ 1408.33
S PIPING.: 0 ft HOOD........... 1 0-3 HP....... 0 BATH TUBS........... 2 DRINKING FOUNT.: 0
FURN<100K... 1 DUCT WORK...... 0 3-15 HP...... 0 SHOWERS ............. 2 SUMPS........... 0 q
GAS HWT.... : I WOOD STOVES...: 0 15-30 HP....: 0 LAVATORIES.........: 4 VAC BREAKERS...: 0
CONY BURNER: 0 FURN>100K.....: 0 30-50 HP....: 0 SINKS ..............: 1 DRAINS.........: 0
BBQ......... 0 MISC........... 0 5+ HP........ 0 DISH WASHERS........ 1 LAWN SPRINKLERS: 0
GAS DRYER..: 1 AIR HANDLING UNITS FUEL TANKS--------- r ELEC WTR HEATERS...: 0 OTHER FIXTURES.: 0
RANGE......: 1 <:10,000 CFM: 0 ABOVE GROUND: 0 LAUN WSHR OUTLTS...: 1
pp GAS LOGS...: 1 > 10,000 CFM: 0 UNDERGROUND.: 0 }1
L_._`--______.'_"_..__'_^_".cc;co-r_•nm.-_::_»_c=-c:^.c::.r.::., �aw�_........_.._�........_s.____y.___..M-,::_�._a-z:===^------""---'"-"•.....__---..________„..__............_......_......- cr.::"•� :�_;��_ .•ca�_oxcc�,s: x,^_�c::�-::r�^aor-� :::
PERMITS EXPIRE 180 DAYSAFTER ISSUANCE IF NO WORK IS STARTED. RESIDENTIAL AND GRADING PERMITS EXPIRE ONE YEAR AFTER DATE OF ISSUANCE.
I CERTIFY THAT THE NF TION F S ED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THE APPLICABLE CITY OF FEDERAL WAY REQUIREMENTS WILL BE MET.
OWNER OR AGENT DATE _ _-� _� (2--')a
G �.!U...---------------------._-..._--.._._-_.-_--____..._.__._._..._____...______... --------____�1_
FILE COPY
..� G City of Federal Way
APPLICAJR BUILDING PERMIT
DEC 0 51995
vq ryUILDING njAL WAy I s} 1 APPL ICA TION #:_ V 1 lJ�lB
11
PLEASE PRINT
L t.'1��QN Address
Lot #
r�
Address
1-10-3o
Zip
C a' CA y )'1
Assessor's Tex #
I;" bjr-,
Phone '8 —7 7(:�jO
Narr0 (F,M,L)
Ad r ss
\'n�
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City hLL
k 'LUI
Phone
Statel
w r 1
Zip
Tact Perso
Day Phone
Other Phone
Fax
om en Name
Address
i' Ake C� Y) C
-
C ntact Perso (
ConAr ctor's # car m st be presente
c c� j�
)(A i `tL-
State UAJ Y"
Phone
Zip
Fax
'&-) -7- I-/oM
Verified ❑ Yes ❑ No
Name
Addr ss
l._. 1A._ v —c 10
City � { _
State W
Zip �,(
l
Contact Perso
��,,<���-> - ra�yLCaq
Phone
Fax
CRIPTION
Please Complete Reverse Side
CD0492 (Rev 41931
� S11 uiJCTURCd :',
AZ'.zs
�Z=. 1`1 f �11 �e w J ,
V
ng Use
alf
XL
Zip
Permit includes:
Phone
❑ Building
❑ Plumbing
Expiration Date
Type of Work:
Residential
❑ Commercial
IX Now
❑ Addition
❑ Remodel
❑ Garage
14Miscellaneous
Enter 1 st Floor 1 � sq ft
Area Basement sq it
2nd Floor 3–D— sq ft
Docks sq ft
3rd Floor sq ft
Garage r'4 sq ft
Boilers
Water Availability
(S�, Sewer Availability 0 On -Site Septic System Availability ❑
Duct Work
Zoning
I
Lot Size iI , (' `�
`)
>NUirlt
Wosed Use 1 ,,uf(IIo C
❑ Mechanical ❑ Othe
❑ Number of Units _ Jock
❑ Shed ❑� Other
Existing Floor Area sq ft
Proposed Total Areo sq ft
............
Name
AZ'.zs
�Z=. 1`1 f �11 �e w J ,
V
City
State ( J T--) Zip 19 S
114)✓CHANICA� CO. NT AC7"bY2 � C� I
Contractor Name
Address
City
State
Zip
Contact
Phone
Fax
License #
Expiration Date
Verified ❑ Yes ❑ No
rxYrnu;rrG Cor�mA c�ou n
Contractor Name
Address
City
State
Zip
Contact
Phone
Fax
License ry
Expiration Date
Verified ❑ Yes ❑ No
i'LUAIB�TG k'!�7'UTtE COUN'�'
Water Closets
..............................
Sinks
I Urinals Lawn Sprinklers
Bathtubs
Z Dish Washers
Drinking Fountains Other
Showers
2 Electric Water Heaters
Sumps
LavatoriesWL4
Iashing Machine
Drains
t' Total; Frctlf re:;Caunt.„.; ...,..
11 I:C.11"ICAL
.................................:.
Fuel Type (electric/other)
Gas Dryer
Air Handling < = 10,000 CFM
15-30 Tons
Length of Gas Piping
Range
Air Handling > = 10,000 CFM
30-50 Tons
Furn <1OOK BTUs
Gas Log
Unit Heater
50+ Tons
Furn > 100 BTUs
Fans
14Miscellaneous
Fuel Tanks
Gas Hwt I
Hood
Boilers
Above Ground
Conv Burner
Duct Work
0-3 Tons
Underground
Q s
Wood Stoves
3-15 Tons
T6tal>:U11jt CUuht . ;
DISCLAIMER: I certify under penalty of perjury that the Information furnished by me Is true and correct to the best of my knowledge and further that 1 am authorized by the owner
of the above premises to perform the work for which permit application is made. I further agree to save harmless the City of Federal Way as to any claim (including costs, expenses,
and attorneys' fees incurred In invefti eti on 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 c im rises 'ut 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. /
zjzOwner/Agent: Date:
(, I fY 01 f, I ". Vt,_RAI._ WAY
33530 t i rSt WaY SC) ars
I odpral Kvv, WA 191900'4
661-4000
M)LVILS�;:629 !,; .3-11ST PI
NO. : 1'321.40-0370
PROJ1( f DESU11f)1`10N-."
CMM GM, 101 1137.
W I L M N(PL11M I I ISSULD: 12/19/95
Building Inspection kequest!; 661-4140
V/PtIquilm; im 'ImIAMI(fit.
€, Vww Cl `z:•,c r. -ca .,. :c« - =......._r:_.:4---:
CMffj GLEN 11b 11TIRIMS111)
4030 U MASH 10. VD N1, VOI
KIMANO VA 1033
*22-7100
OLVA N[C?:X PLIP:X
1 or WK:KV WA:Kfs
CENSIPS LATEGORY.....A.01
oomwy Qt* -------
:KJ :U1
lypt (If ('1)NSIRHCIIOV
54 :A :? ?
occumol tow
0: 0: 0. It
IOU lyllts.:Gfis ?
PIPING : 0 ft
N<Itw..: I
hAS M1....: I
COMM 104RNIR: 0
Sit(}......... 0
"'AS DRYER..: I
RWA ..... .: I
GAS 10GS ... : .1
-PERMITS EXPIRE 180 DAYS AMP
Pt'"11M I I NO: 13L D95 - 0987
LLNK� -
MILYGON w (WARY SLAIIII IMMAU
4030 LK w4so KVP 91 729 wam ANN[ Aw N
SUITE Vol SMILL VA `11IM'
KIRKLANV MA IM131
822-7790
BY: KI (_
L IRL-- ' 11 9 91
XP iwi"W611
Aw Vi!M r.4u9 .....t.;1
ORP Pt AN ......... V FELLS:
S11. 806: 11orb PAKKIW...: 7 PIAN cutcy m ji 414.8`1
2 0391 :f WN'01 No"M
ON Pug KS pta(sr)-93 t 40-90
f.-" IN FINAL PLAN CHECK—* 0.00
, 0
.. ........ BUILDING FUNIT. M.50
isu I v
v t 4.50
how.-
;DI t
950
pa"Mix Fixt .... 9:T3 9lt 03
on- rf SENSIFIVI Offas?.1 rimat nfix ma ... s so.00
am,
a q#w
NPERV SM
iV
`1
ol tNttIDIIN,ms.n
0
FUSN", ...: soft tits/cowassm, Mull aVATS ...... 3 URMS ....... 9 1014t I w; 187"1.511
HOOD... . 1 0 (WINKING FOUNI.: 0
W I VORK.—.: 0 3 -IS W..
"Ps ... ...... 0
wMo VMS.... 0 15-30 11P.-.: 0 1 LAVA4091b.... 4 W IREAKERS.. .: 0
fURN400I.... _: 0 JO -SO 11P .... 0 !;INKS ...... I BRAINS ......... 0
"IS(. .. . ...... 0 51 lip.......; 0 bIq VASMS ....... I LANN SHIMUS. 0
AIR HANDtIN UNIts tuft, IAmKS------ Of( VIA 0 Oluti fixims.: 0
<19,000 ON: 0 ADUVE GRmdo: 0 1.4um USM Mitts-- I
10,M) ON, 0 URN-RGROOND.: 0
IS';Mt. It W) M IS �411*10. RLSIDURIIAI AND GRADING Pf"Ifs UP191 14ul ;LAR At UP bAlf 01, JSsowt.
I (1:111fY UPAI Illf 101:0110411011 IMPILP NY 111 Is 19"t AND (ORR(cl to liff, flt�l of NY MAMIE AND Ulf APPLICABLE MY Of FFRIMAI NAY VIQUIREM11h 4111 K of].
16
FIELD COPY
IcTlY Or FEI)EVAL WAY
433 rd first, way south WILDING PERMIT
Federal WAY, 414 98003 Building fnspoction Reque-s#:�; 661-4140
661--4000
ADDRESS:629 S 331SI' PL.
NO.: 132140-0370
PRO JECT oEscRip rf cm —NSF msf W/PLUMBING AND NE(HANI(AL.
CAMPUS GLEN, LOT #37.
OWNER .... ........ m- .... CONTRACTOR .......
CAMPUS GLEN LTD PARTNERSHIP POLYGON OW COMPANY
4030 LK WASH BLVD HE, 1201 4030 LK WASH BLVD HE
tIRYLAND WA 98033 KIRKLAND WA 98033
-7700
822-7700
PERMIT' NO: BLD95-0981
ISSt)ED: 12/19/95
BY: KLC
EXPIRES: 1,2/19/96
LENDER
SEATTLE MORTGAGE
229 QUEEN ANNE AVE H
SEATTLE WA 98109
its SALES TAX FOR PROJECTS VIININ Iff CITY OF FEDERAL VAY. TAX RATE = 8.2%
TT TA'f
BLD?:X M[C?:X PLN?:X FLR--EX 0P - - -
LP PLAN. :SR FEES:
TYPE Of WORr:H[W USE -RES 1ST e806:sfp-�8- LAN CHECK FEE 474.83
CENSUS CATEGORY ..... :101 21kI# oaf bII(IGHt A S PUB WKS PLCK(SF)..93 F 40.00
F A L H CHECK... 0.00
IR
OCCUPANCY GROUP ------ O,UA R
13 :U1 :? :? tT f IST" .......... PERMIT .... 730.50
TYPE Of (ONSTRUCTION-- UPC ": ......
I ..: 5.00 It WATER SERVICE -:FED SVC( SORCHARGE.....t 4.50
X"Z
:? :? -""#tA# .......... 5.00:ft SEWER SERVICE -:FED ME( APPI.IANCE FEES -1
QC(UPAHT LOAD ------------ 4*"00 ............. I PLUMBING FIXT .... 93t 98.00
o", 7"Pi
0: 0: 0: 0: TOT IMPERV SURFACE: 1925 sf SENSITIVE AREAS?.:N
L TYPES.:GAS ? FANS..........: 4 BOILERS/COMPRESSORS WATER CLOSETS......: 3 URINALS........; 0 TOTAL FEES1408.33
PIPING.: 0 It 0000........,.: 1 0-3 HP......: 0 BATH TUBS..........: 2 DRINKING FOUNT.: 0
DUCT WORK..,..: 0 3-15 HP.....: 0
SHOWERS ........... 2 SUMPS..........: 0
1'
6A'� NWT....: 1 WOOD STOVES ... 0 15-30 HP..... 0 LAVATORIES ......... 4 VA( BREAKERS ... : 0
COMV BURNER: 0 FURN4009 ..... 0 30-50 HP....: 0 SINKS.. ........ 1 DRAINS.. ....... : 0
BBQ......... 0 MIS(........... 0 54 HP........ 0 DISH 04SHERS ....... I LAWN SPRINKLERS: 0
GAS DRYER..: I AIR HANDLING UNITS FUEL TARXS --------- ELF( WIR HEATERS...: 0 OTHER FIXTURES.: 0
RANGE......: 1 !:10,000 Cf": 0 ABOVE GROUND: 0 LAUR WSRR OOTLTS .. I
GAS LOGS...: 1 10,000 CFN: 0 UNDERGROUND.: 0
....... . ............
pPERNIIS EXPIRE 180 DAYS AFTER ISSUANCE If NO NOOK IS STARTED. RESIDENTIAL AND GOADING PERNIIS 10111 0#1 YEAR AFTER DATE Of Issowl.
I CERTIFY INAT THE 111fowlION FURNMED BY ML IS TRUE AND QULO TO THE KSI (4 MY IM EDGE AND 101, APPLI(ftK[ CITY Of FEDERAL MY REQUIREMENTS DILL K NET.
OWNER OR AGENT DATE
FIELD COPY