12-10253611
CITY OF 'A
Federal WgECEIVED 0 PERMIT MF
0— _42� -5 -3
O ME PL DE EN 0
COMMUNITY DEVELOPMENT SERVICES, O[ rI O�� p p L I C A'T I O N7* P a
253- 835 -2607• FAX 253 - 835 -2� N J C
wmil. rih ede�alunl. com � c re/1
CXry OF FEDERAL WAY
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SITE ADDRESS
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SUITE /UNIT M
PROJECT VALLUATION
Al ()"C' .
ZONING
ASSESSOR'S TAR /PARCEL N
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TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERIN FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
'^ _
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
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V
RY�
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MAILING ADDRESS
G
CITY
STATE
ZIP
/
NAME��
NE
CONTRACTOR
MAILING D J C
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E-MAIL
IM`
CITY �
S� E
2IP
FAX
WA 3 TE CT ',4 TS M
`bE-/I TION DATE
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FEDERAL WAY BUSINESS LICENSE 0
NAM
E
PHONE
APPLICANT
MAILING ADDRESS
EMAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
NAME
MAILING ADDRESS
E
CITY
STATE
ZIP
FAX
v
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
(RCW 19.27095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
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 (iwclu ing costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by an ers i eluding the undersigned, and filed against the city,
but only where such claim arise out of the reliance of the city, inc in officers and employees, upon the ccur cy of the
information supplied to the city a part of this application. 1
SIGNATURE: \� � �(�✓ �1 �1 DATEt 1 .
PRINT NAME:
Bulletin #100 —January 1, 2011
`l Page 1 of 3
k:\liandouts\Permit Application
.L/\
VALUE OFMECHAMCAL WORK $
Indicate how many of each type of fixh
AIR HANDLING UNITS
AIR CONDITIONER _
BOILERS
COMPRESSORS
DUCTING
Indicate how many of each type
BATHTUBS (or Tub/ shower Combo)
DISHWASHERS
DRAINS
DRINKING FOUNTAINS
HOSE BIBBS
CRITICAL AREAS ON PROPERTY?
EXISTING /PREVIOUS USE
to be installed or relocated as
FANS _
FIREPLACE INSERTS
FURNACES _
GAS LOG SETS _
GAS PIPING
bid or estimate must be provided
art of this project. Do not include
GAS PIPE OUTLETS _
HOODS )commercial)
_ HOT WATER TANKS )cas)
_ REFRIGERATION SYST
WOODSTOVES
to be installed or relocated as part of this project. Do not include
LAVS IHand Sinks)
TOILETS _
RAINWATER SYSTEMS
URINALS _
SHOWERS
VACUUM BREAKERS
SINKS (Kitchen /utility)
WATER HEATERS (Electric)
SUMPS
WASHING MACHINES
WATER PURVEYOR
LOT SIZE (In Squa a Feet)
a fixtures to remain.
OTHER (Describe)
,.g fvctures to remain.
WATER PIPING
OTHER (Describe)
SEWER PURVEYOR I VALUE OF EXISTING IMPROVEMENTS
EXISTING FIRE SPRINKLER SYSTEM? I PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 — January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application