21-101843-Building Permit Application-5-13-21-V1CITY OF
Fedjeral Way
PERNaT NUMBER
SITE ADDRESS
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7—-5"
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S
/�J% UITE/UNIT !
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX/P CSL 6 �} i/�1
TYPE OF PERMIT
❑ Bul
DING ❑ PLUMBING 11 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION!
Detailed description of work to
h ±444 <
be included on this permit only
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PRIMARY PHONE
PROPERTY OWNER
& AD
RAss
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CI
STATE
ZIP
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NAME
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PHONE
MAMMGADDRESS
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CONTRACTOR
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ZIP
ty
WA STATE
ONTRACTOR'S LICENSE 9
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE @
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NAME
PRINARY PHONE
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APPLICANT
CITY
STATE
ZIP
FAX
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PROJECT CONTACT
NAME
PRBMRY PHORE
XMLM° AM
DRESS
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E-MAM
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(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAb
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW 19.27.095)
MAILING Al
DRESS, CITY, STATE, ZW
PHONE
I certfy under penalty of perjury that I c
Lm. the property owner or authorized agent of the property owner, I certify that to the best
of my knowledge, the information submitte
all applicable City of Federal Way regulati
in support of this permit application is true and correct. d certify that 1' will comply with
ns pertaining to the work authorised by the issuance of a permit. I understand that the
issuance of this permit does not remove
he 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 oft
reliance of the city, including its officars and employees, upon the accuracy of the
information supplied to the city as apart oj
this application.
4
SIGNATURE:
DATE L
PRINT ro
0
Bulletin #100 - January 29, 2016 1 Page 1 of 2 k:IHandoutAPermit Application
MECHANICAL PE ��YnweOFMECHANICAL WORK
Indicate how many of each type offixtu e to be installed or relocated as part of this proiect. Do not inctude exfstiUfixtures to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Des ribel
AIR CONDITIONER FIREPLACE INSERTS HOODS (c= y
_— BOILERS FURNACES HOT WATER TANKS Icb+)
__ COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING
WOODSTOVES
PLUMMING PERMff VALUE OFPLU 'WORK
Indicate how many 2f each type Offlxtw e to be installed or relocated as art o this ro'ect. Do not include axis ' res to remain.
BATHTUBS (o.nuls>c, LAYS (Heed sue+] TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS (s tc 4wNwry] WATER HEATERS (elm
HOSE BIBBS SUMPS WASHING MACHINES TOTAL BDtTIIRF.e
GEWEd2AII, INFORMATION
ia�,z=ixrra
-
AREA Da •r •,.square-�...n
77777777777
•-•••
BASEMENT
FIRST FLOOR (or Mobile Home)
COVERED ENTRY
Are.Z Totals ' r