12-102024ECEIVE
MY OF PERMIT
Federal Way
COMMUNITY DEVELOPMENT SERV A 0 9AP P L I CA'T I O N
253- 835 -2607• FAX 253 -835 -2609
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C1 Y P `F FEDERAL WAY
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MF CO ME PL DE EN FP
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SITE ADDRESS
�S +G 130f
ITE /UNIT #
PROJECT VALUATION
$ 4�aLI
ZONING
�J fa
ASSESSOR'S TAX /PAR$EL #
— A— — — - — — — —
TYPE OF PERMIT
DING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
1�.:
PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
PROPERTY OWNER
NAME
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PRIMARY PHONE
MAILING ADDRESS
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E-MAIL
CITY
STATE
ZIP
.
NAME
PHONE
MAILING ADDRESS
EMAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE #
ERPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
c�Qv�1e
PHONE
MAILING ADDRESS
08102 l3 ' P So
E -MAIL
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APPLICANT
CITY
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Le l (")C,
STATE
STA I,
ZIP
R t,
FAX
PROJECT CONTACT
(The individual to receive and
E A P P L 3 C ,A N T
PHONE
MAILING ADDRESS
E -MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME.
PHONE
E-MAIL
PROJECT FINANCING
NAME
/
OWNER - FINANCED
Required value of $5,000 or more
'v
MAILING ADDRESS, 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 a part of this application.
(city �as
SIGNATURE: AJ y1M /t "r�\� DATE
PRINT NAME: 1A) &, J.k c- 4 ✓► i e_�
Bulletin #100 —January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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 /sh.we combo)
LAVS (Hand Sinks)
TOILETS
VALUE OF MECHANICAL WORK $
DISHWASHERS
(a copy of bid or estimate must be rooded), .
Indicate how many of each type offixture 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 )com erciai)
BOILERS
FURNACES
HOT WATER TANKS
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 /sh.we combo)
LAVS (Hand Sinks)
TOILETS
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitdxn /utaty)
WATER HEATERS (Electric)
HOSE BIBBS -
- -- SUMPS
WASHING MACHINES,
CRITICAL AREAS ON PROPERTY? WATER PURVEYOR
EXISTING /PREVIOUS USE LOT SIZE flu Square Feet)
SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 —January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application