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Q.� G City of Federal Way sRECEIVED
v APPLICATION FOR BUILDING PERMIT AL 2 1 1994
GA.OF DE L'WAY
PLEASE PRINT APPL/CAT/ON #: rte ..—� .) I
SITE LOCATION Address 2 v 2 S c,. '"I;'. G/Ii-- IzkJ/gizet_ &„,)/1-1
Tenant (if known) Lot # Assessor's Tax#
TO‘f5 ?X2)04 4
F•W. CLINIC
Building Owner Name Address
P fir.S . 41 4- ctxviiN6 tot- l'' /yam (? )
City -- r`a ,,; r., , u State C6- Zip C1 !l l u If, Phone
Nature of Work 7e/W)r/vT /rktp off{? ;'I ,
APPLICANT 1
Name (F,M,L)
Address
33y- 20 711, dy- S, (g)
City / Z )t /.'P1t -' State
Zip t'vye.k.-•
Contact PersonDay Phone CJ _G/1 Other Phone Fax G vi .q 21 3
CC ��o 1j(:-) U I G — C> `
BUILDING CONTRACTOR .1
Company Name
i�Lt It-
Address
City State Zip
Contact Person Phone Fax
Contractor's # (card must be presented) Expiration Date Verified ❑ Yes 0 No
ARCHITECT
Name
�
6‘)G.Au0 frg4 0716--(1-1.,
Address
City State Zip
Contact Person Phone Fax
LEGAL DESCRIPTION
Please Complete Reverse Side
CD0492(Rev 4/83)
•
STRUCTURE Existing Use I Proposed Use al-
Permit includes: ❑ Building D Plumbing ❑ Mechanical D Other
Type of Work: D Residential D New D Remodel 0 Number of Units 0 Deck
0 Commercial 0 Addition 0 Garage 0 ShedD Other
Enter 1st Floor"FK'` //sq ft 2nd Floor sq ft 3rd Floor sq ft Existing Floor Area rq 7r"VO sq ft
Area Basement sq ft Decks sq ft Garage sq ft Proposed Total Area sq ft Yf�
Water Availability 0 Sewer Availability 0 On-Site Septic System Availability 0 Project Valuation $ r'.Z-.0'05:0-0 f.�,Sr:!
Zoning - Lot Size Existing Bldg Valuation $ .2,57 po.
. 411 i'f ((,CYSt5-P
LENDER
Name Address
City State Zip
MECHANICAL CONTRACTOR
1Contractor
Name /� Address
City State Zip
Contact Phone Fax
License # Expiration Date Verified 0 Yes 0 No
PLUMBING ACTOR
CONTR
Contractor Name Address
(T g r31to)
City State Zip
Contact Phone Fax
License # Expiration Date Verified 0 Yes 0 No
PLUMBING FIXTURE COUNT
Water Closets , NE v.l Sinks Urinals Lawn Sprinklers
Bathtubs Dish Washers Drinking Fountains Other
Showers Electric Water Heaters Sumps
Lavatories N r1' Washing Machine Drains Total Fixture Count i
3 u AA,/
MECHANICAL UNIT COUNT M/ ' _
Fuel Type (electric/other) Gas Dryer Air Handling < = 10,000 CFM - 15-30 Tons
Length of Gas Piping Range Air Handling > = 10,000 CFM 30-50 Tons
Furn <100K BTUs Gas Log Unit Heater 50+ Tons
Furn >100 BTUs Fans Miscellaneous Fuel Tanks
Gas Hwt Hood Boilers Above Ground
Cony Burner Duct Work 0-3 Tons Underground
BBQ's Wood Stoves 3-15 Tons Total Unit Count
DISCLAIMER: 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 authorized by the owner
of the above premises to perform the work for which permit application is made.I further agree to save harmless the City of Federal Way as to any claim(including costs,expenses.
and attorneys'fees incurred in 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 arise,out of the reliance o e Cit luding its officers and employees,upon the accuracy of thea information supplied to the City as a part of this
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application. /V//Ct'iPiz-L- ii- ,dOI4—/-�t/d/3 iA1U�/-J( 10 I Data: ��2/7Cig
Owner/Agent: C
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