19-100926REaci c:n
FEBMIT APPLICATION
CITY OF
}' 2 b 2019PERMIT CENTER + 33325 8u Avenue South + Federal Way, WA 98003-6325
Federal Way ERAL WAy 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
OF
CO`MMUf NfTYDEVELOPMENT
PERMIT NUMBER -/ q- _ -ZVV"" / � _
V Lo—/ TARGET DATE
SITE ADDRESS
IS -W -
SUITE/UNIT #
PROJECT O�i1 TION
ZONING
ASSES R'S T� �#
TYPE OF PERMIT
❑ BUILDING ❑ PLLUUMBING MECHANICAL ❑ DEMOLITION ❑ ENGINEERIN PREVENTION
NAME OF PROJECT
(❑^
l\21 �,1 i\
k T� aN
PROJECT DESCRIPTION
Detailed description of work to
t,. ; tJ �
n
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAULING ADDRESS E-MAIL
CITY
STATE I
ZIP
NAME I P ONE c
" cr�l S
M6MING ADDRESS/ -C MAIL
Z'� 21-5 Ac/,,–`��
CONTRACTOR
CI Y M 1 C h1
STATE
ZIPFAX L
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE #
NAMEP Y PHONE
P te, 20 s ,1 t 3 jb
_
ADD
MAILING ✓ ` S i
An
�MAtL i
t lS
Wim:
APPLICANT
CITY
STATE
7�ip VIA FAX of
PROJECT CONTACT
NAME - PRIMARY PHONE
Or
MAILING ADDRESSQ111!5-
l.- 1 �s V �� , 1r�
(The individual to receive and
respond to all correspondence
CiRy
STATF,
FAX
concerning this application)
PROJECT FINANCING
NAME�' ❑ OWNER -FINANCED
When value is $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 certtfy 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 c m), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city of this tion.
SIGNATURE: rDATE
PRINT NAME: c—
Bulletin #100 – January 29, 2016 Pa 1 of 2 k:\Handouts\Permit Application
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT $
Indicate how many of each type of fixture to be installed or relocated as part of 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
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
VALUE OF PLUMBING WORK
PLUMBING PERMIT
... ................ _._._............. -----....._..-----------------..- ..... ............. _._..
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
$
Indicate how many of each type offixture
to be installed or relocated as
part of this project. Do not include existiri�g fixtures 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?
FIRST FLOOR (or Mobile Home)
❑ Yes ❑ No
❑ Yes ❑ No
RESIDENTIAL - NEW OR ADDITION
AREA DESCRIPTION (in square feet) EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
... ................ _._._............. -----....._..-----------------..- ..... ............. _._..
FIRST FLOOR (or Mobile Home)
__............ --.... _..................................... ........................................._.........................._._............_....__.
Oil&
COVERED ENTRY
...._.._......_...__.... _.._..... .... _. _..__..._............ _._r ________...._...___...................
GARAGE ❑ CARPORT ❑
�f
------.................. _._............................ _............. __........ _......... _.._._................... --
Area Totals EXISTING
PROPOSED
TOTAL
:. f
ESTIMATED SELLING PRICE $ # OF BEDROOMS
COMMERCIAL -NEW/ADDITION
Area is Construction # of
AREA DESCRIPTION Souare Feet Occupancy Groups) TvDe Stories Additional Information
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
Area inConstruction # of
AREA DESCRIPTION Square Feet _ Occupancy Tune Stories Additional Information
TENANT AREA ONLY
Bulletin #100 — January 29, 2016 Page 2 of 2 k:\Handouts\Permit Application