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"mit #,
CITY OF FEDERAL WAY
BUILDING PERMIT APPLICATION
— Please Print —
BOX 1 TENANT NAME:
OWNER e uee6-y0ZiS&1
OWNER'S ADDRESS
DESCRIBE JOB
THE PROPERTY IS OWNED BY
SITE LOCATION
CITY L -J
v = .?3
PHON e-
LE/MARRIED PARTNERSHIP- -CORPORATION
BOX 2 CONTRACTOR'S NAME ,�0- 5JOMA CONTRACTOR'S REG. # 1E C 5 Y? l 3Av
CA Card MUST be presented
CONTRACTOR'S ADDRESS l07 0-3 Ack S- f�. CITY �� PHONE F917 9V4AJ
EXPIRATION DATE �' 2 'T I
-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 P _ _ _- PHONE_
BOX 4 SEWER DISTRICT
BOX 5 ESTIMATED PROJECT COST
BOX 6 PROPERTY TAX ACCOUNT
LEGAL DESCRIPTION A
WATER DISTRICT
EXISTING BUILDING VALUATION
(If necessary, please submit a separate page with the legal description.)
K.C. Plat Recording #
v
BOX 7 BUILDING SQUARE FOOTAGE: (Existing/Proposed)
1ST FLOOR / 2ND FLOOR —J—
3RD FLOOR / BASEMENT
1 _ DECK ______/_ GARAGES
BOX 8 ( 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 $ 0�
NO._,_5'WIITERCLOSETS
GAS PIPING, FEET - _ _
$
BATHTUBS
N0. FURNACE, ELEC. GAS
$-
SHOWERS
GAS HOT WATER HEATER
$
LAVATORIES
CONVERSION BURNER
$ 1PU ' -
BOILER, SIZE BTU
$ ALL—
_--Z-SINKS
AIR HANDLING UNITS
$ �5:
_LDISHWASHERS
EKff"C 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
- -
- $ -
$
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 ASTO 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, BUTOW WHERE SUCH CLAIM ARISES OUT OF THE RELIANCE OF THE CITY, INCLUDING ITS
OFFICERS AND EMPLOYEE,UPfWTH;ACRAC O/THE INFORMATION SUPPLIED TO THE CITY AS A PART OF THIS APPLICATION.
OWNER/AGENT:
DATE: -S Z F
ANP -009 3190
OFFICE USE ONLY (PLEASE -DO NOT WRITE BELOW THIS LINE)
ZONE SETBACKS: FRONT_—. SIDE. REAR_ HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL _
REMARKS:
SEPA: EXEMPT NOT EXEMPT
FIRE DEPARTMENT APPROVAL
REMARKS:
PUBLIC WORKS DEPARTMENT APPROVAL
REMARKS:
DATE
DATE—
TYPE OF JOB: NEW RESIDENCE RES- ADD/ALT NEW INDUSTRIAL IND. ADD/ALT
NEW COMMERCIAL— COMM. ADD/ALT NEW MULTIFAMILY (UNITS )
MULTIFAMILY ADD/ALT TENANT IMP. OTHER
OCCUPANCY _ TYPE OF CONSTRUCTION _-- _STORES
BUILDING SO. FT. _ _--_... @
--- __ BUILDING SO. FT.. — _
BUILDING SQ. FT. _... @ _
..... _... BUILDING SO. FT.
_-- BUILDING SQ. FT. @
....... BUILDING SQ. FT......-... _
_ @ _
TOTAL SQ. FT. --- TOTAL VALUATION --
BUILDING DEPARTMENT REMARKS:
RECEIVED
ASSIGNED ADDRESS:
Amount
BY
PARTIAL PLAN CHECK FEE RECEIVED
.---Date - ......... Receipt #
BUILDING DEPARTMENT APPROVAL
OATE
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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