12-103009N RECE11W
Federal Way PERMIT
COMMUNnY DEVELOPMEW 0429
2W-835-2607- FAX 253-835-26092AKLpPLICATION
www.atuot(ederalwau.m ii OF FEDERAL WAY
CITY CDS
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SITE ADDRESS -Ilk /°
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SUITE/UNIT #
PROJECT VALUATION
ZONING
ASS ESSOR'S TAX/PARCEL #
$ Vj '560-60
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
t7'enantName/HOrneownerLast Name)
PROJECT DESCRIPTION
Detailed description of uaork to
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be included on this permit only
PROPERTY OWNER
Nnea/'
PRIMARY PHONE
Z /MAILING ADDRESS -
E-MAIL
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CONTRACTOR
CITY
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WA FTATE CON/T`R/ACdTOR'S LICENSE #
EXPIRAATTION DATE
FEDERAL" BUSD6SS LICENSE #
NAME
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PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
—
FAX
PROJECT CONTACT
Nn
PHOIYE
rMe individual to receive and
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respond to all correspondence
concerning this application)
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STATE
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ALTERNATE CONTACT NAM
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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 ation.
SIGNATURE: DATE O ///t
PRINT NAME:
Bulletin #100 —January 1, 2011 Page I of 3 k:\Handouts\Permit Application
ee, H"
MECHANICAL FIXTURES
PLUMBING FIXTURES
2
MEC
VALUE OF IMMCAL WORK $ c/ ,4D D, a 0 (a copy of bid or estimate must be provided)
BATHTUBS (n,9Wb/sb—rcnmbn)
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS
(MIER (Describe) `1A(
AIR CONDITIONER FIREPLACE INSERTS HOODS (c ... e -ii)
1411121--k
BOILERS BOILERS FURNACES HOT WATER TANKS (css)
11(et! P5
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
SUMPS WASHING MACHINES TOTAL FIXTURES
DUCTING GAS PIPING WOODSTOVES
GENERAL INFORMATION
PLUMBING FIXTURES
Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existing futures to remain.
BATHTUBS (n,9Wb/sb—rcnmbn)
LAVS (nand Sinks) TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS
SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kia-brn/Uumy) WATER HEATERS (Eir<tno
HOSE BIBBS
SUMPS WASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
TOTAL
FOR OFFICE USE
BASEMENT
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
ADDITION
❑ Yes piQ No
Yes r� No
RESIDENTIAL
- NEW OR ADDITION
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
BASEMENT
FIRST FLOOR (or Mobile Ilome)
ADDITION
SECOND FLOOR
COMMERCIAL - REMODEUTENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
COVERED ENTRY
Construction
# of
Stories
Additional Information
'I'(TCAL BUILDING
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
PROJECT AREA ONLY
Area Totals
eusrwc
mora
TOTAL
**NEW HOMES ONLY**
I:STIMA-ITD SELLING PRICE $
1 # OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area
m Square Feet
Occupancy Group(s)
Construction
Type
# of
Stories
Additional Information
NEW BUILDING
ADDITION
COMMERCIAL - REMODEUTENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
# of
Stories
Additional Information
'I'(TCAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin #100 - January 1, 2011 Page 2 of 3 kAlHandouts\Permit Application