19-10106840k
CITY OF
Federal Way
PERMIT NUMBER ! _
RECEIVED
MAR o f 2019 PERMIT APPLICATION
CITY OF FEDERAL WAYPERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
COMMUNITY DEVELOPMENT 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
- _ TARGET DATE
NA
SITE ADDRESS
SUITE/UNIT #
I C
/V �Vj ' 554 ✓ I ,
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
s b y °�
07 5 Q _ / o / 6
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING R FIRE PREVENTION
NAME OF PROJECT
0l- 56I+ sr�y
PROJECT DESCRIPTION®L
_ _ 41
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY
ZIP
/STATE
NAME f 1 i1Y 6
PHON
2-53
MAILING ADDRESS�® �
EMAIL ��
CONTRACTOR
CITY
STATE
w
ZIP
�� �fq0
FAR
,,1l
.253-�6s
WA STATE CONTRACTOR'S ENSE #
TD
FEDEY�S LICENSE #
/ OZ-
��JJ�
0�����XI
19 -
NAME 5
Ta#N0 tD
PRIMARY PHONE
MAILING ADDRESS�� PO
M( 9
E-MAIL
APPLICANT-
CITY
STATE
ZIP
�Lg
FAX
NAME /�, /j,�l� ^' O`
M f AS
PRIMARY PHONE
PROJECT CONTACT
�J --P1 ✓
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
conceming this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $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 to the city as a part of this application.
SIGNATURE: - DATE 03 QtLV
�Gl�
PRINT NAME: t1' f^✓� 1
Bulletin #100 — January 29, 2016 Page 1 of 2 k:\HandoutsTermit Application
VA
MECHANICAL PERMIT LUE OF MECHANICAL WORK
Indicate how many o each type grfixture to be installed or relocated as part o this project. Do not include existing res to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (commercial)
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
PLUMBING 'PERMIT s
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existing res to remain.
BATHTUBS (or Tub/shower combo) LAVS (Hand sinks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS 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?
❑ Yes ❑ No
❑ Yes ❑ No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet) EXISTING PROPOSED
TOTAL
FOR OFFICE USE
r
---.......... ..._............ _..... .... --................... -..... _ ............ -. _.......... _......... ---... -
FIRST FLOOR (or Mobile Home)
............................................................................... _... __._.......___ —.- - -
"
COVERED ENTRY
......... _.. ....................
GARAGE ❑ CARPORT ❑
r� F sr1gy
,11
Im 1-012
Area Totals EXISTING PROPOSED
TOTAL
n ,
.. r
fWr
�..n,
ESTIMATED SELLING PRICE $
# OF BEDROOMS
Bulletin #100 - January 29, 2016
Page 2 of 2
k:\Handouts\Permit Application