10-103524��cETv�v PERMIT
Federal
rO,yyr•M7TDFW10PMWF,VrSkR1R'S85+ a10 APPLICATION
3.5.1-R-3S-xr.67• FAX 25,74,lls-160
CITY OF FEDERAL
CDS
MF CO ME PL DE EN 6
SITE ADDRESS � � � ^ SVITE/VNIT p
PROJECT VALUATION ZONING ASSESSOR4'S /PARCELM
TYPE OF PERMIT ❑ BUILDING ElPLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION r _i
Detailed description of work to
be included on this permit only
PROPERTY OWNER
CONTRACTOR
APPLICANT
MAILING
CITY
NAME
CITY
b QC
WA STATE CC
l:_ L ru
CITY r
PRIMARY PHONE
E-MAIL
STATE I ZIP
PHONE
3TA'L'I¢� ZIPF i
R'3 LICENSE N 1�- iEXPIRATION DATE FEDERAL WAY BUSINESS LICENSE S
i-060055
PHONE
C.
STATE ZIP
Im
PROJECT CONTACT
NAME • 0
PHONE
(The individual to receive and
ti
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTI NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
7 OWNER -FINANCED
Requiredv m
MAILING DRESS, C STATE, ZIP
' �4
PHONE
9_2
6t� . ire = rs.�
ti5
I certify nderpenalty ofp
ry that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knawl ge, the infarmati
submitted In support of this permit application is tree and correct. I certify that I will comply with
all applicable ty of Federal W
regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of thilp, I does no remove the owner's responsibility for compliance with local, state, or federal Laws regulating
construction ore ironmental law
arm
I further agree t hold harmless the Uty of Federal Way as W any claim (including costs, expenses, and attorneys' fees incurred in
the investigation an of su h claim), which may be made by any person, including the undersigned, and fled against the city,
but only where at c
s out of the reliance of the city, Including its officers and employees, upon the accuracy of the
information supplied to city
ap this application.
SIGNATURE:
DATE
PRINT NAME:
W ! L
Bulletin #100 — April 14, 2010 Pagel of 3 k:\Handouts\Permit Application
VALUE OF MzcHANICAL WORK i (a copy of bid or estimate must be provided]
Indicate how many of each type of fixture to be installed or relocated as part of this project Do not include existing frxt as to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (commercial)
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate how many of each type of fixture to be installed or relocated as part of this project Do not include existing fixtures to remain.
BATHTUBS (or Tub/shower combo) LAVS (H=dsiaks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS (xitehen/utility) WATER HEATERS (Ekcuiq
HOSE BIBBS SUMPS WASHING MACHINES
Bulletin #100 — April 14, 2010 Page 2 of 3 k:\Handouts\Perrnit Application