15-100207CITY OF
Federal Way
PERMIT NUMBER 15 _ 10 0 Z 0 7�_ 00
JAN 21 2015
CITY OF FEDERAL WAY
TARGET DATE CDS
SITE ADDRESS
icy 5,--o3v<o — «cF� / ��W
SUITE/UNIT #
PROJECT VALUATION
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ZONING
ASSESSOR'S TAI{/PARCEL #
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME
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PRIMARY PHONE
-5? L) 73 41 /(p C) ,,
MAILING ADDRESS
/D y $ t- t2 3 C7C7
E-MAIL
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CITY.
STATE ZIP9 8 o . _3
NAME
C> w.�tJF
PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
n
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
NAME
PRIMARY PHONE
PROJECT CONTACT
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
El OWNER -FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as apart of this application.
SIGNATURE: i .i�� t—) DATE
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PRINT NAME: / �J 13 / C v ` F
Bulletin #100 - January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT s
Indicate how many of each type o re to be installed or relocated as part of thisproject. Don include existing rest main.
AIR HANDLING UNITS FANS GA$ Pj4 OUTLETS .� (Describe)
AIR CONDITIONER FIREPLACE INSERTS , HOODS (coon =4 C �
BOILERS FURNACES HOT WAAR TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING_ WOODSTOVES
PLUMBING. PERMIT _
AREA DESCRIPTION
VALUE OF PLUMBING WORK
Indicate how many of each type of fixture•to be installed or relocated cis part
of this project. Do not include existing res to remain.
BATHTUBS (or Tub/shower combo) LAVS (Hand Sinks)
DISHWASHERS RAINWATER SYSTEMS
DRAINS SHOWERS
DRINKING FOUNTAINS SINKS (Kitchen/ututy)
HOSE BIBBS SUMPS
TOILETS WATER PIPING
URINALS OTHER (Describe)
VACUUM BREAKERS
WATER HEATERS (Eiectric)
WASHING MACHINES TOTAL FIXTURES
NEW BUILDING
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?
❑ Yes ❑ No
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
Area
in Square Feet
Occupancy Group(s)
Construction
Type
RESIDENTIAL - NEW OR ADDITION
Additional Information
TOTAL BUILDING
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
BASEMENTr;:
PROJECT AREA ONLY
FIRST FLOOR (or Mobile Home)
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (describe)
.... -----...-----
---._........... ............................ ——.._.._...........--.........
Area Totals
EHISTING
PROPOSED
TOTAL
"NEW HOMES ONLY**
ESTIMATED SELLING PRICE $
# OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
# of
Stories
Additional Information
NEW BUILDING
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area
in Square Feet
Occupancy Group(s)
Construction
Type
Stories
Additional Information
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin #100 —January 1, 2013 Page 2 of 3 k:\Handouts\Permit Application