05-105695 P
City of Federal Way
Community Development Services Mechanical Permit #: 05 - 105695 - 00 - ME
PA.Box 9718
Feceral Way,WA 98063-9718
Ph:(253)835-7000 Fax:(253)835-2609 Inspection request line: (253) 835-3050
Project Name: KOZAK
Project Address: 30819 4TH 5l PI 5 Parcel Number: 241330 0870
Project Description: Replace gas furnace.
Owner Applicant Contractor
Emery L Kozak &Donna M Kozak GATEWAY HEATING&AIR CONDITION GATEWAY HEATING&AIR CONDITION
30819 4TH PL S 3802 AUBURN WAY N 3802 AUBURN WAY N
FEDERAL WAY WA AUBURN WA 98002 AUBURN WA 98002
98003-4044 (253)931-0610
Mechanical Valuation 2000 Over the Counter Permit Yes
Mechanical Fixtures
Description Quantity Description IQuantityj'L Description [Quantity
' Furnaces I
CONDITIONS:
This parcel is located within a Wellhead Protection Area(Capture Zone 1)and must comply with FWCC,Chapter 22,
Article XIV"Critical Areas" and fill out a Hazardous Materials Inventory Statement,if applicable.
PERMIT EXPIRES May 3,2006.
Permit issued on November 4,2005
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and the use will be in accordance with the laws,rules and regulations of the State of Washington and
the City of Federal Way.
Date: /
Owner or agent: 4
THIS CARD IS TO REMAIN ON-SITE
CI OF Community Development Inspection Record
Federal Way IVR INSPECTION REQUEST PHONE # (253) 835-3050
PERMIT #: 05-105695-00-ME
Owner: EMERY L KOZAK
Address: 30819 4TH PL S
FEDERAL WAY, WA 98003-4044
This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD.
Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not
be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence. On-going inspections
are logged on the back of this card.
0 Mechanical Rough-in(4165) ❑ Gas Piping(4125) 0 Final-Mechanical(4065)
Approved Approved to release test Approved
By Date By Date By G cod
d Date((7 Z,4-�
I
.:A . RECEIVED .
Federal Way - d S .,�
comartTYSEVELOFYENrSERVICES NOV 0 4 PERMIT SF MF C + LPL DE EN FP
33325:w AVENUE SOUTH•PO BOX l71:
..,
FEDERAL WAY,WA !:06347 , ° p L I C AT I O N
153:35Y6o7•FAX 253135 71'9p pE jj
....iipiiir,
wuw.aernllede.oti,.�.._... BUILDINq pEWAY
The oilowi • is re• ired in ormation-an Inco •lets . ••lication Will not be acce•ted. ass ,rint le• •1
3019(�
le PROPERTY INFORMATION or �.
SITE ADDRESS '-14t_ p( . S •
LI SUITE/UNIT#
ASSESSOR'S TAX/PARCEL$ L 1 3 3 0 - 0? '1 0 LOT SIZE(sf
LEGAL DESCRIPTION(e.g.Acme Estates,Lot 1)
oskichWanisrq.far lengehY legal draaijdry
■ PROJECT INFORMATION
TYPE OF PERMIT 0 BUILDING 0 PLUMBING MECHANICAL
0 DEMOLITION 0 ELECTRICAL 0 ENGINEERING 0 FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION(Provide detailed description of work included on this permit only)
._)CL-70 l fa 2 s VLA:n c-r--
PROJECT NAME(Name of Business or Owner Last Name) -
MI PEOPLE INFORMATION
PROPERTY NAME PRIMARY� PHONE
OWNER �Yti��/{(/� o•�.,-)� I (WJ ) %c51 - 2309
MAILING ADDRESS Q I� P
3O8R L P1 S . 6.50. 82(003
CONTRACTOR COMPANY NAME APPLICANT NAME OFFICE PHONE
` ��1L rJ �sl (c353)4/ -C6010MAILING ADD STATE,ZIP CELL PHONE
• 3TDZ IN # 301 42101an l�.,A Q%Oft ( ) -.
•
CITY OPFEDERAL WAY BUSINESS LICE SE NUMBER EXPIRATION DATE -- FAX NUMBER
1 Ci.-.e (4.--.4 Q �-D ��-B L IZ/ 31 /o S- (Z.3) FIN- 6 049
CONTRACTORS REGISTRATION NUMBER(copy of sari rs¢Irsi witk sack application( EXPIRATION DATE
APPLICANT CQ1i�NAME APPLICANT NAME OFFICE PHONE
�U * Oc (Z53) 931 -t�,0
MAILING ADDRESS ,STATE,ZIP - CELL PHONE
SM Anburn L 43D I OWA oz. ( ) -
RELATIONSHIP TO PROJECT FAX NUMBER
o Architect a Tenant a Agent o Other(Descrllre) ( 3) '71144 - 014(o0
CONTACTRESS
S PRIMARY ONE ,E-MAIL ADD
_ ‘i 4...ktitit 4.4-16. (7A )
6i31 - 6(.010
0611A4.4.)4016cliing awl.
LENDER
MAILING ADDRESS COY,STATE,ZIP
• DETAILED BUILDING INFORMATION
EXISTING USE PROPOSED USE
EXISTING ASSESSED/APPRAISED VALUE $ VALUE OF PROPOSED WORK $
SPRINKLERED BUILDING? o YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED? a YES o NO
WATER SERVICE PROVIDER a LAKEHAVEN Cl RIGBLINE 0 TACOMA 0 PRIVATE(WELL)
SEWER SERVICE PROVIDER a LAKEHAVEN a HIGHLINE 0 PRIVATE(SEPTIC)
•
PROJECT FLOOR AREAS
AREA DESCRIPTION EXISTING PROPOSED TOTAL
SQ.FT. SQ.FT. SQ.FT.
BASEMENT
FIRST •
SECOND
THIRD
FOURTH •
ADDITIONAL FLOORS(DESCRIBE) -
DECK(COVERED?)
GARAGE 0 CARPORT 0
NUMBER OF FLOORS =STOW PSOrosso ?OTM. toraiso I si
"NEW HOMES ONLY" NUMBER OF BEDROOMS ESTIMATED SELLING PRICE $
FIXTURES
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
MECHANICAL
Value of Mechanical Work $ a .00
•
AIR HANDLING UNITS EVAPORATIVE COOLERS GAS LOGS REFRIG.SYSTEMS
BBQS FANS HOODS(c. i s WOODSTOVES
BOILERS • , FIREPLACE INSERTS RANGES MISC(Describe)
• COMPRESSORS I' FURNACES GAS WATER HEATERS
DUCTS GAS PIPE OUTLETS
PLUMBING
BATHTUBS wrub/ah werC..b.) SHOWERS WATER CLOSETS crake MISC(Describe)
DISHWASHERS SINKS DRINKING FOUNTAINS
GAS PIPE OUTLETS SUMPS RAINWATER SYST
WASHING MACHINES URINALS HOSE BIBBS
LAVS iearuoo.siolui VACUUM BREAKERS ELECTRIC WATER HEATERS
DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the Information furnished by me is true and correct to the best of my knowledge,and further,that I
am authorised by the owner of the above premises to perform the work for which the permit application is made. 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 of Federal Way,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.
NAME/TITLE ,i1( DATE � ( dle/ O
(Signature) (Title)
RELATIONSHIP TO PROJECT a Owner a Agent a Contractor ❑ Architect a Other
Fri;'! .b t)'-)t't`(ci f 41'G id'ti(c) 2 d6Ctl;i "I {Vu i'i I,,I:)C1c)'f; .',11.i`1f re
: ;Ii,c) rc, ziteri�t,6, e7if1',. a.:0(c i,,v;r' —:Q�y 40'
t (e C i.j ',(ct i;:?,1Nr ;d:s, rai ;.:>:'' ^::; jc1
•
Bulletin#100—January 7,2005 Page 2 of 4 k\Handouts\Permit Application