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r.1Ti O�ralV1� EIVEL PER'T
FeiCOMMUNITY o8V&OFN8NT Sl; C s 2 9 2 0 I OA P P L I C A T I O N
253-835-2607• FXX 253.535-
iuiuw..'ti a + � • ni
fTry np FFIDERAL WAY
SITE ADDRESS C
1,'I ClAx,
ZONING
PROJECT VALUATION
BUILDING
TYPE OF PERMIT ❑ DEMOLITION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) G
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit Onl?]
_ - - — -- — �NAME
PROPERTY OWNER
AILING
CONTRACTOR
APPLICANT
PROJECT CONTACT
[7'he individual to receive and
respond to all oorrespondenoe
concerning this application)
PROJECT FINANCING
Required value of $5, 000 or more
(RCW 19.27.095)
U - / V 3
SF MF Co ME PL DE EN FP
T
Z
he
ce
SUITE/UNIT #
ASSESSTAX/PARCEL # y
❑ PLUMBING ❑ MECHANICAL
[I ENGINEERING ❑ FIRE PREVENTION
M
CITY
NAME
w^
MAILING ADDRESS
CITY
WASTATE CONTRACTOR'S LICENSE # ,
NAME � m�
MAILING ADD SS
d.
CITY
NAME
t
MAILING ADDRESS
CITY
ALTERNATE CONTACT NAME:
NAME
MAILING ADDRESS, CITY, STATE, ZIP
S,-TA�TE Z
E� v
S,TIATE ZIP.�� Jq�
EXPIRATION DATE
P/jig 1/;�
STATE I ZIPP
k" 7 i
STATE I ZIP
PHONE
PRIMARY PHONE
E-MAIL
PHONE 1-5- —1
E-MAIL
FAX
FEDERAL WAY BUSINESS LICENSE #
PHONE
E-MAIL C
FAX f!ir7�I�+�fi G
PHONE
E-MAIL
FAX
E-MAIL
OWNER -FINANCED
PHONE
er ur filar f am the property owner or authorized agent of the property Darner. I certify that to the best
I certfy under penalty of P J y Port ❑ this permit application is true and correct. I certify that I wilt comply with
of my knowIle ,ties ir�orneatlon suhslitted in DPP q compliance with
local, state, or federal laws regulating
all applicable City of Federal Way regulaiivns pertaining to the work authorized
cnirepd b2J the issuance of a permit• I understand that the
issuance of this permit does not remove the owner's responsibility costs, expenses, and attorneys' fees incurred in
construction or environmental laws.
which maybe made by any person, including Lhe undersigned, and jtlhe against lice city,
i further agree to hold harmless flee City of Federal Way as to any claim jinciu ngcers and employees, upon the accuracy of the
the investigation and defense of such claim], he including its offs
but only where such claim arises gout ort f this reliance
of t city,
ir{jormatian supplied to the city
� DATE
SIGNATURE:
PRINT NAME:
Bulletin # 100 —April 14, 2010
Page 1 of 3
k:\llandouts\Perinit Application
MECHANICAL FIXTURES
{a co y o bid or estimate must be rovidedl
o this ro e°i. Do not include exi5tin tocribe)rems to
VALUE OF MECHANICAL WORK
R
(Desixt
each t e ° Dcture to be installed or relocated as art O
GAS PIPE OUTLETS
GAS Indicate how IltOlR ° p
AIR HANDLING UNITS
FANS
FIREPLACE INSERTS HOODS (commercial)
AIR CONDITIONER
FURNACES
ITS
HOT WATER TANItj�{G.y1
BOILERS
COMPRESSORS
GAS LOG
REFRiGERAT1dfSYST
WOGZ7STpVES
DUCTING
GAS PIPING
PI. MgNG ups
I, as port ° this project. Do not include existing fixtures to remain.
TOILETS WATER PIPING
Indicate how many of each t pe ❑f fixture to be installed or relaeu
OTHER (Describe)
LAYS (xa as,iltW URINALS
BATHTUBS (or'Rib/Shower Combo) RpJN�"SYSTEIuiS
DISHWASHERS
ERS VACUUM BREAKERS
DRAINS
DRINKING FOUNTAINS
S
WATER HEATERS (Z t c)
SINKS (K tchen/UTyI TOTAL FIXTURES
WASHING MACHINES
HOSE BIBBS
SUMPS
GENERAL INFORMATION
OF EXIST INGTMPROVEMENTS
CRITICAL AREAS ON PROPERTY?
VALUE
SEWER PURVEYOR 32 ` 0 0
W%P VE�d Q
Ae PROPOSED FIRE SUPPRESSION SYSTEM?
EXISTING FIRE SPRINKLER SYSTEM?
LOT SIZE (In 8 aria 6�-d'f�J,l�,�jr
EXISTIIPGIPREVIOUS USE
�7/(/
❑ Yest�No
T
o� /
RESIDENTIAL -- NEW OR ADDITION
EXISTING PROPOSED TOTAL FOR OFFICE USE
AREA DESCRIPTION (in square
feet)
BASEMENT
FIRST FLOOR (or Mobile Home)
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE CARPORT ❑
OTHER (describe)
EXISTING
Area Totals
— —.
**NEW HOMES ONLY**
# OF BEDROOMS
ESTIMATED SELLING PRICE
Co M M ERCIAL--NEW/ADDIITIONCo
tion #of Additional Information
--
Area Occupancy Group(S) a Stories
AREA DESCRIPTION
in S uare Feet
NEW BUILDING
ADDITION
i M OD i, UT 1'%N ANTI MPRO ME # of
COMMERCIAL-
vn Additional Information
Area Occupancy Group(s) a Stories
AREA DESCRIPTION
in S uare Fee
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ON
k:\Handouts\Permit Application
Page 2 of 3
Bulletin # 100 — April 14, 2010
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