09-104295Z�Zeq RECE*VED
�,-Ws
Novo 3 'PERMIT
Federal Way
commuAuTYDEVELOPMENT siQUl ( OF FRMWATI O N
253- 835 -2607• FAX 253- 835 -2609
www.ciluo(federahnau. com
SF MF CO ME EL PL DE EN FP
INS,�.�$��� f3
SITE ADDRESS ,\ �� ` , 0 1
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SUITE /UNIT # ZONING ASSESSOR'S TAR /PARCEL #
r s
NAME OF PROJECT
(Tenant or Homeowner Name)
G
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERNIIT
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING VIFIREE PREVENTION
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PROJECT DESCRIPTION
Detailed description of work to�
d
be included on this permit only
.,�'yG„�`ef,:,,��,3 x. i?.
.9iidY9r7G:' 3 i' � fi � X , ,f ✓ /:i .d
NAME -.
PRIMARY PRONE„ ,
PROPERTY OWNER
MAILING ADDRESS,,QftY. STATE, ZIP
E -MAIL.
OWNER IS ALSO:
❑ CONTRACTOR APPLICANT ❑ PROJECT CONTACT
NAME
PRIMARY PHONE
-
2T 14col) A,-jil pL,(crS &Rs-)ic6�5
(ZC*) 7??-4,- 0914 t)
MAILING ADDRESS, CITY, STATE, ZIP
b 1 co 12 :1" A,,t tj,,,c E S, ArR E 04 9810
FAX
( Z06) 7b7- Z1>0 7
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
A-t µ0o o cs �scc l-
)Zi 1 1 l
NAME
PRIMARY PHONE
,ran
JAI S Gi-F -J 4� F�2 /t —40D �
(2o 6) ��z b - o 9 y o
APPLICANT
Mi4MING ADDRESS, CITY, STATE, ZIP
FAX
(2-06)7 6-r- 2-b27
PROJECT CONTACT
NAME
PRIMARY PHONE
(171e individual to receive and
J-41 .5 C P ^) E[e L
(Zn (b ) 7 N - o 7 L! O
MAILING ADDRESS. CITY, STATE, ZIP
FAX
respond to all correspondence
concerning this application)
100 RT"- J 5 • S 4TA r ,(, W 0. `j IK 10 Fi
(2o b ) -710'7 - 21p O
ALTERNATE CONTACT NAME:
PRIMARY PHONE
E-MAIL
21sT --A! F2I
(?_b 172,6- O9tt6
5d-tKdo Go moo �e
PROJECT FINANCING
NAME
OWNER- FINANCED
Required for projects with
MAILING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
value of $5,000 or more
(RCW 19.27.095)
r ) _
\owner.
I certify under penalty of perjury that I am the property owner or authorized agent of the property I cert(jg that to the
best of my knowledge, the information submitted in support of this permit application is true and correct. I cert(y 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.
Ifurther 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.
1
SIGNATURE: DATE ` U
PRINT NAME: \ A Y Sc Hf-J C::B L 7
Bulletin #100 — 4/21/2009
Page 1 of 4
k:\Handouts\Permit Application
wL
0
Value o Mechanical Work $ (A COPY OF BID OR ESTIMATE MUST BE PROVIDED)
Indicate number 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 (commercial)
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
GENERAL
INFORMATION
PROJECT VALUATION
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
$ to 55
EXISTING /PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
❑ Yes ❑ No
Bulletin #100 — 4/21/2009 Page 2 of 4 k:\Handouts\Permit Application