19-100970RECEIVED
CnY OF FEB 2 8 2019
Federal Way
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
PERMIT APPLICATION
PERMIT NumBzR `�1 — v' O —j�
L TARGET DATE
SITE ADDRESS
SUITEMNIT M
�WI U SW 0Z3
'ala
PROJECT VALUATION
ZONING
ASSESSOR'S TAXJPARCEL e
$1 Z; 03L4
U0 m "(1 .
2 5 2 1 U
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING VFIRE PREVENTION
NAME OF PROJECT
V9-:4MLTJ
e) I d(A
PROJECT DESCRIPTION
Detailed description of work toJIVIQ.
572
be included on this permit only
NAME �
�
PRDIARY PHONE
PROPERTY OWNER
LL
MAILING ADDWM
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E -MAD.
CITY
STATE
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NAME N, C
PHONE ' Z
rren.naGADDREEs 3rd �1 D1L;v�neax�n�v�.�.
5,
CONTRACTOR
CITY w+
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FAX
WA STATE CONTRACTOR'S LICENSE 0
NO�i� S
zxPxRATION DATE
OZ
FEDERAL WAY BUSUIESS LICENSE e
Z Cie
120 12000
Z OD
NAME
PRIMARY PRONE
2
MAZDIG ADDRESS C
As PV, Q
EQMA�-n�SYT15
APPLICANT
CITYTAT ZIP
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FAX
20x0• -n2.-1SO4
NAME,
PRIMARY PRONE
CONTACT
'2.OQ - -77Z' 150-2-
502(TPROJECT
MAILING ADDRESS
E-MAIL
(The
he individual to receive and
respond to all correspondence
1(,eXt�-
STATE
i v
2IP
q� o37-
FAX
- -"Z - -7 90 '
concerning this application)CITY
PROJECT FINANCING
NAME
N O T- Tb O u 2
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 authorised 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 authorised 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 city of this application.
�,�aQs�apart
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SIGNATURE: - U ZGV`v QR, }J �V�P DATE
PRINT NAME: �Qf I d 12 l (�✓ Y �DYW�J� fi �° SUS Ff'�VY�S
Bulletin #100 — January 1, 2013 Page 1 of 3 k:\Handouts\Pernrit Application
M
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT $
Indicate how M04of each type offixture to be installed or relocated as part of this project. Do not include e;dstingfixtures to remain.
AIR HAN ING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR C DITIONER FIREPLACE INSERTS HOODS (commerew)
B ERS FURNACES HOT WATER TANKS Gas)
OMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
GENERAL INFO TION
CRITICAL AREAS ON FRO
WATER PURVEYOR
VALUE OF PLUMBING WORK
PLUMBING PERMIT
EXISTING/7 USE
LOT SIZE (In Square Feet)
EIIZSTaiG FIRE BPRnua&R. SYSTEM?
$
Indicate how magiofeach type offixture
to be installed or relocated as
part of this project. Do not include exis
' res to remain.
r Tub/Shower Combo)
LAVS (H—dSwr.)
TOILETS
WATER PIPING
RS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
/NKING
SHOWERS
VACUUM BREAKERS
UNTAINS
SINKS (rjtch—/utility
WATER HEATERS (Electric)
SUMPS
WASHING MACHINES
TOTAL FIXTURES
GENERAL INFO TION
CRITICAL AREAS ON FRO
WATER PURVEYOR
BEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
EXISTING/7 USE
LOT SIZE (In Square Feet)
EIIZSTaiG FIRE BPRnua&R. SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
❑ Yes ❑ No
Bulletin #100 — January 1, 2013 Page 2 of 3 k:\Handouts\Pemiit Application