14-104638CITY OF A
Federal Way
PERMITtAPPLICATION
PERMIT NUMBER _ l_(� _
-- — — — TARGET DATE
RISCEIVED
SEP 10 2014
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SITE ADDRESS
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PROJECT VALUATION
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TYPE OF PERMIT
❑ BUILDING El PLUMBING 1-1 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME
PHONE
''2
t
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
d
rWA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
NAME
PRIMARY PHONE
PROJECT CONTACT
2!2'q 1 t
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
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 to the city as apart of this application.
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SIGNATURE: - DATE / f ' Z�Z
PRINT NAME:
Bulletin 4 100 - January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
It ,00' -
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT s
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existingfixtures 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
VALUE OF PLUMBING WORK
PLUMBING PERMIT Is
Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existingfixtures to remain.
BATHTUBS (or Tub/Slower 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
FOR OFFICE USE
AREA DESCRIPTION
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
in S uare Feet
❑ Yes ❑ No
❑ Yes ❑ No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
AREA DESCRIPTION
Occupancy Group(s)
FIRST FLOOR (or Mobile Home)
Additional Information
in S uare Feet
Y$E f f?TiJ FYAoiz
Stories
COVERED ENTRY
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GARAGE ❑ CARPORT ❑
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COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
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Area
Area Totals
EffiSTRPO
PROPOSED
TOTAL
WHOMS
01M
Additional Information
ESTIMATED SELLING PRICE $
# OF BEDROOMS
COMMERCIAL- NEW/ADDITION
Area
Construction
# of
AREA DESCRIPTION
Occupancy Group(s)
Additional Information
in S uare Feet
Type
Stories
/
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
Area
Construction
# of
AREA DESCRIPTION
Occupancy Group(s)
Additional Information
in Square Feet
a
Stories
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TENANT AREA ONLY
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Bulletin #100— January 1, 2013 Page 2 of 3 k:\Handouts\Permit Application