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11-100260Y CITY OF Federal Way COMMUNITY DEVELOPMENT SERVICES 253 - 835 -2607• FAX 253 -835 -2609 www. dWo((ederalwauxo 0 PERMIT APPLICATION (I- 1002 &-q qF MF CO ME PL DE EN FP RECEIVED IAN 9 n 7 %'1 SITE ADDRESS SUITE /UNIT # ©0 S . 31` (�J l CITY OF EDERAL WAY PROJECT VALUATION ZONING ASSESSOR'S TAR /PAR L # C�S $�-i$� -.00R - - - - - -- - - -- TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION NAME OF PROJECT (Tenant Name /Homeowner Last Name) CO. /> i V^ PROJECT DESCRIPTION t + 1 "'1 — NiAA3 Detailed description of work to l� be included on this permit only NAME PRIMARY PHONE PROPERTY OWNER MAILING ADDRESS E-MAII. CITY STATE rUME I rG{� PHO 3— U Ii�WG 1 DRESS / E-MAD: ONTRACTOR , STAT FAX / � A E CONTR 'C X".. EXPIRATION DATE �NSE # ' FEDERA L WAViV bB q — PHONE APPLICANT Q jADD E -MATT. STATE FAX PROJECT CONTACT PHONE (The individual to receive and respond to all correspondence ING; DRESS E-MAIL AIL E(h concerning this application) �� 11623 1E- STATE Ja FAX ---"� _a- _ zn> I Z ALTE CONTACT NAME: PHONE E•MAD. PROJECT FINANCING NAME OWNER- FINANCED Required Value of $5.000 or more MAILING ADDRESS, CITY, STATE, ZIP PHONE (RCIV 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 Wormation 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 ftied 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 tgformation supplied to the city as a part of this application. l SIGNATURE. DATE 1 I "r, PRINT NAME: —A�d'o Bulletin #100 - January 1, 2011 Page 1 of 3 kAHandouts\Pennit Application aM VALUE OF MECIMNIC L 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 (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 f xtures to remain. BATHTUBS (or Tub /shower Combo) LAVS (hand sinks) TOILETS WATER PIPING DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe) DRAINS SHOWERS VACUUM BREAKERS DRINKING FOUNTAINS SINKS (Kitchen /Utaity) WATER HEATERS (electric) HOSE BIBBS SUMPS WASHING MACHINES CRITICAL AREAS ON PROPERTY? I WATER PURVEYOR I SEWER PURVEYOR I VALUE OF EXISTING IMPROVEMENTS EXISTING /PREVIOUS USE LOT SIZE (In Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM? XYes ❑ No ❑ Yes ❑ No Bulletin #100 — January 1, 2011 Page 2 of 3 kMandoutsTermit Application