94-102096 a..� , • City of Federal Way •
APPLICATION FOR BUILDING PERMIT q y,
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PLEASE PRINT APPLICATION #:/6L / 9 L'—Og 0
SI E LOCATION Address ',:-.12t5 � ;.L; 4c A4 -t.. 1( 7
Tenant (if known) A Lot # Ass s or's Tax #
Building Owner Name Address
b'Y11� t 2 Sou T4c V f
City - j.c �Cca ( �.�c�s-� State L*-Jct jZip p 9 f C.)Q' (Phone g3�— �c)1C3
Nature of Work 1y tom�l Y1 ) g 4 ' T 1►115(A �c''c- c254„Lry- 3pgc
APPLICANT
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Name (F,M,L) - )1L
/,KJI v� ' AMPS"
Addressair 2 �—T� c
City �(— p (@ VC-I( State 4
Contact Person Day Phone Other Phone •a- :x
Company Name
Address
City
State Zip
Contact Person Phone Fax
Contractor's # (card must be presented) Expiration Date Verified ❑ Yes ❑ No
Name
Address
City State Zip
Contact Person Phone Fax
LEGAL DESCRIPTION
Please Complete Reverse Side
CD0492(Rev 4/931
STRUCTURE • sting Use Ooposed Use
Permit includes: Building ❑ Plumbing ❑ Mechanical ❑ Other >
Type of Work: ❑ Residential ❑ New ❑ Remodel ❑ Number of Units ❑ Deck
❑ Commercial ❑ Addition ❑ Garage ❑ Shed ❑ Other
Enter 1st Floor sq ft 2nd Floor sq ft 3rd Floor sq ft Existing Floor Area sq ft
Area Basement sq ft Decks sq ft Garage sq ft Proposed Total Area sq ft
Water Availability ❑ Sewer Availability ❑ On-Site Septic System Availability ❑ 'Project Valuation $
Zoning Lot SizeExisting 61dg,\l;gfuation $
LE:
N .
Name Address
City State Zip
MECHANICAL'CONTRACTOR
Contractor Name Address
City State Zip
Contact Phone Fax
License # Expiration Date Verified ❑ Yes ❑ No
PLUMBING CONTRACTOR
Contractor Name / Address
cSor�Y�=.- -c,c VI v ml I l�L �,G O . p,
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City o?�C., V1 V l`SState ux-'"=\ Zip r--?C6 )�
Contact __... i.vi,--1. l YU + Phona�^ __)_7_7Fax jt�.�
License # .5A " e P T P -- Cc.)-7 5 WI IC Expiration Date-71C45 Verified El Yes ❑ No
PLUMBING'FIXTURE;COUNT
Water Closets Sinks 6 Urinals Lawn Sprinklers
Bathtubs Dish Washers Drinking Fountains Other
Showers Electric Water Heaters 2— Sumps
Lavatories Washing Machine DrainsTotal.Ei cture Count
MECHANICAL UNIT COUNT
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 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.
Owner/Agent: Mt� , Ti--)r�/-",Y"_'�,i..--- Date: t`t t (
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