20-101622PERMIT APPLICATION
CITY OF
Federal Way PzRxrT CENTER +33325 8h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenteducityoffederalwav com
PERwT NUMBER 1101046000110 _
-- _ TARGET DATE
SITE ADDRESS
SUIT !
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PROJECT VALUATION
ZONING ASSESSOR'S TABIPARC L M
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
NAME
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PRfafARY PHONE
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PROPERTY OWNER
MAILING ADDRESS
E-MAIL
CITY _P
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PHONE
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CONTRACTOR
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STATE
WA
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FAX
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ElLP6[ATION DATE
►EDERAL WAY BUSINESS LICE E10
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PREMEARY PHONE
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APPLICANT
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PRI1f1ARY PHONE
PROJECT CONTACT
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(The individual to receive and
respond to all correspondence
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concerning this application)
PROJECT FINANCING
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❑ OWNER -FINANCED
When value is $5,000 or more
HAILING Ap OR658, CITY, STATE, ZIP
PHONE
IRCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorized 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 Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, 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 ofJRcers and employees, upon the accuracy of the
information supplied to the city as apart of this application.
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SIGNATURE: DATE
PRINT NAME: -
M
Bulletin 4100 - January 29, 2016 Page l of 2 k:\Handouts\Permit Application
V.
MECHANICAL PERMIT $ gLL'E OF UIECHAVIL'AL WORK
Indicate hole nmn_q Pf inw.h type of [.rture to he &isralled Or retocated as part of this projecr. Do not include exiSting fLrtures ra renlairr.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe(
AIR CONDITIONER FIREPLACE INSERTS HOODS comme«til,
BOILERS FURNACES HOT WATER TANKS ;cui
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Ir1LL'E ❑FPUAMEVC WOW
PLUMBING PERMIT
$
Indicate horn TUAM Of each_ type offixtave
to be installed or relocated as
part of this ro t_ Do not inctude existing fixtures to rem_ain_.
BATHTUBS
LAYS iH.nj 3 ;si
TOILETS
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describel
DRAINS
SHOWERS
VACUUMBREAKERS
DRINKING FOUNTAINS
SINKS rK,t_hen{eW,r:,
WATER HEATERS (EI-cl
HOSE BIBBS
SUMPS
WISHING MACHINES
TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet(
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
Yes - No
- Yes - No
RESIDENTIAL -NEW OR ADDITION
AREA DESCRIPTION (in square feet)
EXISTING
PROPOSED
TOTAL
FOR OFFICE USE
BASEMENT
FIRST FLOOR (or Mobile Home(
SECOND FLOOR
COVERED ENTRY
DECK
GARAGE ❑ CARPORT ❑
OTHER (descnbe)
Area Totals
H%ISTOIG
PROPOSED
TOTAL
"AlKWHOMFS OALY"
ESTIMATED SELLING PRICE $ i# OF BEDROOMS
COMMERCIAL - NEW/ADDITION
AREA DESCRIPTION
Area in
Square Feet
Occupancy Group(s)
f Construction
j e
# of
Stories
Additional Information
Nzw BUILDING
ADDITION
COMMERCIAL - REMODEL/TENANT IMPROVEMENTS
AREA DESCRIPTION
Area in
Square Feet
Occupancy Group(s)
Construction
a
# of
Stories
Additional Information
TOTAL BUILDING
TENANT AREA ONLY
PROJECT AREA ONLY
Bulletin 4100 -January 29, 2016 Page'' of 2 k:'.HandoutsTemnit Application
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