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Permit # ;2 - 0
CITY OF FEDERAL WAY
BUILDING PERMIT APPLICATION
— Please Print —
BOXII TENANT NAME:
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 01� THE INFORMATION SUPPLIED TO THE CITY AS A PART OF THIS APPLICATION.
OWNER/AGENT: DATE: ` iQ - 9 ........
ANP -008 3190
OWNER
SITE LOCATION 3Q, t to S 1LA
OWNER'S ADDRESS _ 1 U -
CITY FLA PHONE c%"f LA —
DESCRIBE JOB w' ' R Ct
;►' c E:—. �J
THE PROPERTY IS OWNED BY: SINGL ARRIE
ARTNEq HIP CORPORATION
BOX 2
CONTRACTOR'S NAME
CONTRACTOR'S REG. #
Card MUST be presented
CONTRACTOR'S ADDRESS
_ CITY- PHONE
EXPIRATION DATE
—OR—
I HAVE READ CHAPTER 18.27.010 RELATING TO DEFINITIONS OF GENERAL CONTRACTORS AND SPECIALTY CONTRACTORS AND
CHAPTER 18.27.110 WHICH PROHIBITS ISSUING PERMITS WITHOUT PROOF OF REGISTRATION. .
BOX 3
CONTACT PERSON
PHONE
BOX 4
SEWER DISTRICT ..........
WATER DISTRICT
BOX 5
ESTIMATED PROJECT COST ...
EXISTING BUILDING VALUATION
BOX 6
PROPERTY TAX ACCOUNT NUMBER
) S= -S C-'
LEGAL DESCRIPTION
(If necessary, please submit a separate page with the legal
description.)
K.C. Plat Recording #
BOX 7
BUILDING SQUARE FOOTAGE: (Existing/Proposed)
1ST FLOOR / 2ND FLOOR
/
3RD FLOOR / BASEMENT _-�
DECK______J_ GARAGE-.--/—.
BOX 8
yip SINGLE FAMILY
( ) NEW CONSTRUCTION
( ) MULTIFAMILY (NO. OF UNITS = )
EXISTING STRUCTURE
( ) COMMERCIAL/INDUSTRIAL
TOTAL AREA OF PROPERTY
SQ FT
BOX 9
PLUMBING FIXTURES (including rough -ins)
MECHANICAL APPLIANCES — BASIC FEE
$
NO-WATERCLOSETS
GAS PIPING, FEET
$ ..
BATHTUBS
N0. FURNACE, ELEC. GAS
$
SHOWERS
GAS HOT WATER HEATER
$
LAVATORIES
CONVERSION BURNER
$
SINKS
BOILER, SIZE BTU
$
DISHWASHERS
AIR HANDLING UNITS
$
ELECTRIC HOT WATER HEATER
HEAT PUMPS, SIZE
$
LAUNDRY WASHER OUTLET
UNIT HEATERS
$
URINALS
AIR COOLING UNITS, SIZE
$
_DRINKING FOUNTAINS
COMMERCIAL HOOD
$
_SUMPS, SPRINKLER VACUUM BREAKERS
_.._.OTHER
$
DRAINS
A CACX 'V'L �
OTHER .... ............
$
_.TOTAL FIXTURES
------
$
TOTAL MECHANICAL FEE
$
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 01� THE INFORMATION SUPPLIED TO THE CITY AS A PART OF THIS APPLICATION.
OWNER/AGENT: DATE: ` iQ - 9 ........
ANP -008 3190
OFFICE USE ONLY (PLEASE DO NOT WRITE BELOW THIS LINL)
ZONESETBACKS: FRONT _ SIDE _ REAR -HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL
REMARKS:
SEPA: EXEMPT NOT EXEMPT
FIRE DEPARTMENT APPROVAL DATE
REMARKS:
PUBLIC WORKS DEPARTMENT APPROVAL, DATE
REMARKS:
TYPE OF JOB: NEW RESIDENCE RES. ADD/ALT NEW INDUSTRIAL_ IND. ADD/ALT
NEW COMMERCIAL_ COMM. ADD/ALT- NEW MULTIFAMILY (UNITS )
MULTIFAMILY ADO/ALT TENANT IMP. OTHER
OCCUPANCY TYPE OF CONSTRUCTION _ STORES
BUILDING SO. FT. @ _
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ _
BUILDING SO. FT. @ _
BUILDING SO. FT. @ _
BUILDING SQ. FT. @
TOTAL SO. FT. TOTAL VALUATION
BUILDING DEPARTMENT REMARKS:
RECEIVED
ASSIGNED ADDRESS:
PARTIAL PLAN CHECK FEE RECEIVED
Amount Date Receipt #
BUILDING DEPARTMENT APPROVAL
BY DATE
PERMIT FEE
PLAN CHECK FEE
PLUMBING FEE
MECHANICAL FEE
TOTAL BLDG. FEES
PART P/C FEE
SEPA REVIEW
S.B.C.C. FEE
OTHER FEES
AMOUNT DUE
ACCEPTED FOR FILING
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DATE BY _ _ ....
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O.K. TO ENCLOSE FRAMING
DATE --,---.---BY - -
FINAL O.K. TO OCCUPY
DATE _1/r,%0I_ 8y _ !"
O.K TO POUR FOUNDATION WALLS
DATE BY
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INSULATION
DATE BY
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_--- DATE _-_ .. -__ BY
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-...__ DATE .... _ _BY
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