13-102760C,rGF 4PERMI10APPLICATION
Federal Way RECEIRD -
JUN 2211 202 z
PERMIT NUMBER 1�-0� `c�a$ m-7( %�
C� tV TARGET DATE J
SITE ADDRESS
I
SUITE/UNIT Ir
PROJECT VALUATION
ZONING
JS
ASSESSOR'S TAX/PARCEL #
I
TYPE OF PERMIT
tl[LDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
t
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PROJECT DESCRIPTION
Detailed description
1'16 L:, h; A /C `) i
of work to
-C(- y ( C -
be included on this permit only
PROPERTY OWNER
NAM , I _ /� n �> ��
I/1C�'� �CC j i lI G� �1
PRIMARY PHONE
),- t - �13L1 ' �Cl/l}
MAILING ADDRESS
) Z >'�- V r✓� 6W
�) One ri'-nc (e
CITY • t
STA'?
ZIPS
NAM
II Fc�12 Nr: on �-✓c�c {i��--
PHONE
�-53--3�,I�/—
MAILING ADDRESS �.,
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E-MAIL
CONTRACTOR
+' Gi C i 1E (t ' i 1 Si a�
CITYK
-e I if
STATE
LV 1+
ZIP
Pc'
FAX
l,c) I '
WSTATE CONTRACTOR'S LICENSE X
L(i c Fl; `� 3 It�•'
EXPIRATION DATE
) q 13
FEDERAL WAY BUSINESS LICENSE N
NAME
r^
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE ZIP
FAX
PROJECT CONTACT
NAME
PRIMARY PHONE
(The individual to receive and
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
PROJECT FINANCING
NAME
10 OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
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 suppp d to the city as apart of this application.
SIGNATURE:�s l_ - ,'>
DATE �• �,
PRINT NAME: f! fir* f
C )v /�1. -lie
Bulletin # 100 - January 1, 2013 Page 1 of 3 k:\Bandouts\Permit Application
101
�cm
MECHANICAL PERMIT VALU F MECHANICAL WORK
Indicate how many of each tjype of fixture to be installed or relocated as part of this ro'ect. o not include existirkgfixtures to remain.
AIR HANDLING UNITS FANS GAS PIP TLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HqJ36S (commeccja)
BOILERS FURNACES OT 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
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
L
-iYes X No
Indicate how many of each type of fixture
t e installed or relocated as
part of this project. Do not include existing fixtures to remain.
BATHTUBS (or Tub/shove= Combo)
L (Hand Siuxs(
TOILETS
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
.,DECK
DRINKING FOUNTAIN
SINKS (Kitchen/utility)
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?
L
-iYes X No
EIYes '.LZ No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
BASEMENT
NEW BUILDING
FIRST FLOOR (or Mobile Home)
ADDITION
SECOND FLOOR
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
COVERED ENTRY
Occupancy Group(s)
Construction
a
# of
Stories
Additional Information
.,DECK
GARAGE ❑ CARPORT ❑
TENANT AREA ONLY
OTHER (describe)
PROJECT AREA ONLY
Area Totals
—STING
PROPOSED
TOTAL
"*NEW sows ONLY*"
ESTIMATED SELLING PRICE $
1 # OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
a
# of
Stories
Additional Information
NEW BUILDING
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
a
# 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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