12-100032CITY Of
Federal way
COMMUNITY DEVELOPMENT SERVICES
253- 835 -2607 FAX 253 -835 -2609
HERMIT
APPLICATION
J-2- -4�
SOF CO ME PL DE EN FP
RECEIVED
7 JAN' U 4�;
3a -7)'�
SITE ADDRESS
1010 S �� �.�,,, CITY OF FEDERAL
SUITE /UNIT M
I&AY
PROJECT VALUATION
$1,600.0o
ZONING
ASSESSOR'S TAX /PARCEL
__q_ _X _�_ z 1) L i 0
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
E v e - e /
!� G.-1�' � �r vQ ill U f Co I,c
PROJECT DESCRIPTION
T21 rD v2
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME ,
0 m ✓t i 1- r0 e✓ �i S
PRIMARY PHONE
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
NAME g.., !Il :� �G- GG�I' —! t � �
2- J 3 6, 3I> 17 i G...
MAILING ADDRESS n
o Go - ` 1 I
E -MAIL
✓ 'fc�fuKsec� t..f f�rl
CONTRACTOR
CITY
STATE
W4
ZIP
9t) y Z
FAX
Zs- & ae o 3 6
WA STATE CONTRACTOR'S LICENSE N
S
EXPIRATION DATE
03/ 2
FEDERAL WAY BUSINESS LICENSE M
lo-&Z -160 -8L
NAME
PHONE
APPLICANT
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
NAME `
�CO�✓ / S
PHONE
MAILING ADDRESS
S4CW� CL 5 co --+Y-
E -MAIL
respond to all correspondence
concerning this applicationj
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
l
PHONE
Zf (e3f 175
E -MAIL
PROJECT FINANCING
NAME
OWNER- FINANCED
Required value of $5,000 or more
7�/IIDAESS, CITY, STATE, ZIP
PHONE
(RCW 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 officers and employees, upon the accuracy of the
information supplied to the city as a part kf this application.
SIGNATURE: ---" DATE
PRINT NAME: h ✓"cy—
Bulletin # 100 - January 1, 2011 Page 1 of 3 kAHandouts \Permit Application
L
i
VALUE OF MECHANICAL WORK $ _ (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 fixtures to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (comm-ii)
BOILERS FURNACES HOT WATER TANKS icas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate how many of each type
BATHTUBS )or Tub / shower combo)
DISHWASHERS
DRAINS
DRINKING FOUNTAINS
HOSE BIBBS
to be installed or relocated as
LAVS JHand sinks) _
RAINWATER SYSTEMS _
SHOWERS _
SINKS )Kh<hen/ Utility) _
SUMPS _
CRITICAL AREAS ON PROPERTY? ( WATER PURVEYOR
EXISTING /PREVIOUS USE I LOT SIZE (la Square Feet)
f this project. Do not include existing fixtures to remain.
TOILETS
WATER PIPING
URINALS
OTHER (Describe)
VACUUM BREAKERS
WATER HEATERS (Ete<trk)
WASHING MACHINES
SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
(000.00
EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 — January 1, 2011 Page 2 of k:AHandoutsTermit Application