11-103886J1* ".,
Federal Way
COMMUNITY DEVELOPMENT SERVICES
253- 835-2607• FAX 253 -835 -2609
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PERMIT
APPLICRR@P/ED
SEP 6 ?e
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MF CO ME PL DE EN FP
app � o
YED
SITE ADDRESS
SUITE /UNIT
2 i ScJJ g'ITSS0PCF-EAERAL WAY(
PROJECT VALUATION
ZONING
ASSESSOR'S T�DSCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
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PROJECT DESCRIPTION
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Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
L� "i�4- ") ��{? _S.J�
PRIMARY PHONE
Z-.'s3 -18
MAILING ADDRESS / %�
E -MAIL
CITY
STATE
ZIP
NAME
PHONE
MAILING ADDRESS
4 3 CT-
E -MAIL
CONTRACTOR
CITY —
1,4r e.a,u A
STATE
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ZIP
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FAX
WA STATE CONTRACTOR'S LICENSE A
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE fl
A:1 > EL_ESr93-iD
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NAME '8 I T't . SPA �t�� rL �lr uaz rC
PHONE
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MAILING
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E-MAIL eTA ?OA e,�I�i�G.
APPLICANT
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STATE
ZIP
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FAX
2s3 -338 - 2k!zv
PROJECT CONTACT
N
PHONE '25 3— �t _ J � 2, i
(The individual to receive and
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MAILING ADDRESS
E -MAIL
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respond to all correspondence
concerning this application)
L c.., -)
CITY_
STATE
2IP
FAX
ALTERNATE CONTACT NAME.
PHONE
E -MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
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 city as a part of this application.
SIGNATURE: �.��- DATE
PRINT NAME: t J C e l-- / �XC_A ✓z-
Bulletin #100 -January 1, 2011 Page] of 3 k: \Handouts\Permit Application
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 HOODSIcommerclaq
BOILERS FURNACES HOT WATER TANKS (Gas)
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 (Hand Sinks) _
RAINWATER SYSTEMS _
SHOWERS _
SINKS (Kitchen /Utility) _
SUMPS
f this project. Do not include
TOILETS _
URINALS _
VACUUM BREAKERS
WATER HEATERS (Eieeuie)
WASHING MACHINES
ng fixtures to remain.
WATER PIPING
OTHER (Describe)
CRITICAL AREAS ON PROPERTY? ( WATER PURVEYOR I SEWER PURVEYOR ( VALUE OF EXISTING IMPROVEMENTS
EXISTING /PREVIOUS USE LOT SIZE (Ia Square Feet) EXISTING FIRE SPRINKLER SYSTEM? I PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
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