19-102620 RECEIVED
4,„„,t1§. 4 PERMIT APPLICATION
CITY OF
Federal Way f t ; I 1�1�
PERMIT MIT CENTER+33325 8th Avenue South+Federal Way,WA 98003-6325
253-835-2607 + FAX 253-835-2609 +permitcenter@cityoffederalway.com
Cfi``OFFEDERAL WAY
G� COMMUNITY DEVELOPMENT
/
PERMIT NUMBER / _. l Q 4' _ � TARGET DATE
L
SITE ADDRESS 421 �fl SUITE/UNIT#
PROJECT VALUATION �� ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING,aFIRE PREVENTION
NAME OF PROJECT t C�r r 1 K
PROJECT DESCRIPTION CH
V {\
Detailed description of work to I yl r 1/l(W �(re c/)C i h�r ter t+51-rifq
be included on this permit only II I
_
NAME _ ... _.. PRIMARY PHONE -.
PROPERTY OWNERa GS ) 10^,S7
ING ADDRESS E-MAIL
rAPcCki)Kke ry0c i( CO4
CITY STATE ZIP d
PHONE
BVI Tire Pmi-Pctior' SsfC,ti �L a��3ls c1�toG
MAILING ADD E-MAIL �
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CONTRACTOR 2CQ I� qNr /rah wt )h� 5 0 fl Ct
sjrsf
C1TTY STATE ZIP _dAX y 'CDyq
WA-STATE LICENSE# tiQ 6, 9K33
WA- ION DATE FEDERAL WAY BUSINESS LICENSE#
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E 1 PRIMARY PHONE
c/U a ra Ick ;1 --,3/r p z�
APPLICANT- INGADDRESS
L L E- L > n 1� [�
1" l I ,/-dc e CITY ST TE ZIP 6YrnF 'irreprote l�5y54ern.�lY
AX
AIME PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
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.
SIGNA tE A‘. . DATE ✓ 3/- /7
PRINT NAME: — /Li A. /-
Bulletin#100-January 29,2016 Page 1 of 2 k:\Handouts\Permit Application
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT $
Indicate how many of each type offixture to be installed or relocated as part of this project.Do not include existing fixtures 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 $
Indicate how many of each type offixture to be installed or relocated as part of this project.Do not include existing fixtures to remain.
BATHTUBS(or-rub/Shower Combo) LAVS(sons 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
<. .a,.,-,..�. ,
FIRST FLOOR(or Mobile Home)
COVERED ENTRY
xaa«€ a
....,«....,,,r, ,,.}: „ya..,,H.:,r«.:ii>n.rz;%M<..;+�,z•+w.i..:w�P ec,_.....r,y;Nr%•wv..,?'tv,+,•�'al.:,•:iw,n,=. ,rdb,a.r„
GARAGE 0 CARPORT 0
EXISTING PROPOSED TOTAL
Area Totals
` .; .• ray� -, "".'.NE�V'?iO�ES��611i�J�',<'," •a "`Y"` ' .." r<:f�,��;:
ESTIMATED SELLING PRICE$ I # OF BEDROOMS
COMMERCIAL—NEW/ADDITION
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
21#1E3UII:DING'',.**: ., ,�,,.`�„"::yj'»,:,�..',;,t:;.Y„y,;.'. ... +rs.,;;;t; , ;;;;;;;„7",;.`,F;,-,., �,,..y.:._;.�'.`-.•;`��.,» '�:« �,
, .i•""/.aza» _ .. > .. . .. '-ter-: .. .:., .., .. ,. ,. •. ,. ,. r„ ,
ADDITION
COMMERCIAL—REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION Area Occupancy Group(s) Construction #of Additional Information
Square Feet Type Stories
Efi, 2 ra /'r,c,///FT w ''H'r(�; 44,', t,: rt... . •2.;' ,> > •i'h, - sv.
Tt7FAL ING W E,. .locL a' j `r,o tsg u, ., %; s,s�:-', %t i
TENANT AREA ONLY
s 'lRO:TLFCT RE ONJ.Yh . , r” ! ;,t k `:,1•71","41.$I"Ik:/i ro
Bulletin#100—January 29,2016 Page 2 of 2 k:\Handouts\Permit Application