11-101281 _ � J1 - ( 0 ► zg1
Federal Way PERMIT •MF CO ME PL DE EN m
COUNIYDPME SERVICES APPLICATION '253-835-2607. 411WIND
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AP 001011 ab CL
SITE ADDRESS
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PROJECT VALUATION ZONING ESSOR'S TAX/PARCEL 0
$5, OOO. q z & 4 S"O - O z O
TYPE OF PERMIT ❑BUILDING 0 PLUMBING 0 MECHANICAL
❑ DEMOLITION 0 ENGINEERING jf FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) Av ` c n��
PROJECT DESCRIPTION CZ Z') 1n.eC S
Detailed description of work to ?veXOCQk1/40.--b \Aeac s
be included on this permit only C�ad9Q Czt �
NAME _ PRIMARY PHONE
PROPERTY OWNER c� -c�p�lc \ ( cP
MAILING DRESS -ri�7`r�C�• \ E-MAIL
co 'C ) \_k 9-CX
ZIP
`c-�'F mSTATE Olggo.(,2b7
NAME PHONE
MIMING
CONTRACTOR PO 0X Vi G eSS ICCI e-CcD631 cc
'/\AATE\ C reser- aSk
efso$z, 4ZSi-42 .81 ?S
�uov't\N1PCONTIWTOR 4 l� � N� � ./q '•inWAT /X"�.
NAME PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
PROJECT CONTACTc PHOONEE
(The individual to receive and N
ed ,\C-d+-(�1 In � 142 ,- g i•VOLO9
respond to all correspondence MAII.D(G ADDRESS E-MAIL
concerning this application) 12.\ lL> Qr .4CQ.e OU7\'V ,`
ZIP
` V\\_ G(�<e� STATE � C> 2- 2215*. 0. 15�7,5s `�"r►Com
ALTERNATE CONTACT NAME: PHONE E-MAIL
PROJECT FINANCING NAME
0 OWNER-FINANCZD
Required value of$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 authorised 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 Wag regulations pertaining to the work authorised by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with focal, 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 he city as a part of this application.
SIGNATURE: f Z. A% DATE Z/. '//
PRINT NAME: L.���l( 4 ) ItiSQ,
Bulletin#100—April 14,2010 Page 1 of 3 k:\liandouts\Permit Application
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VALUE OPMECwAIVICAL WORK $ (a copy of bid or estimate must be provided)
Indicate how many of each type of fixture 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)
rA ,IF CO? )ITION1rR , _ • FIREPLACE INSERTS HOODS(commercial)
BOILERS FURNACES HOT WATER TANKS(Goa)
COMPRESSORS-`'L ! ` GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
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Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existing 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/ut;uty) WATER HEATERS(Electnc(
HOSE BIBBS SUMPS WASHING MACHINES TOTAL FIXTURES
CRITICAL AREAS ON PROPERTY? WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
$
EXISTING/PREVIOUS USE LOT SIZE IIn Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
"Yes❑ No ❑Yes ❑ No
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,,
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AREA DESCRIPTION(in square feet) EXISTING PROPOSED TOTAL FOR OFFICE USE
FIRST FLOOR(or Mobile Home)
SECOND FLOOR ,
COVERED ENTRY
DECK
GARAGE 0 CARPORT 0
OTHER(describe}
=ATOM PROPOSSD TOTAL
Area Totals
-Raw HOMES ONLY"* -
ESTIMATED SELLING PRICE$ #OF BEDROOMS
AREA DESCRIPTION
Area Occupancy Group(s) Construction #of Additional Information
in Square FeetType Stories
NEWBUILDING
ADDITION
AREA DESCRIPTION
AreaConstructionGroupe) Construction #of Additional Information
in Square Feet Type Stories
Tt TAL BUII.Dnit} . 1 r, • - . .
TENANT AREA ONLY
- PROJIEcr ARg Ott* _T_'
Bulletin#100—April 14,2010 Page 2 of 3 k:\I-Iandouts\Permit Application