09-102513NAME OF PROJECT t
(Tenant or Homeowner Name)
❑ BUILDING ❑ PLUMBING ❑ MECHANI�CA^L
TYPE OF PERMIT 11�'f� r °e & R e S C u
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEE
tL-1,rc
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
OWNER IS ALSO:
CONTRACT! R
OV
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
Required for projects with
value of $5,000 or more
(RCW 19.27.095)
NAME i
MAILING ADD S, CITY, STATE, ZIP
E-MAII.
❑ CONTRACTOR ❑ APPLICANT PROJECT CONTACT
NAME
PRIMARY PHONE
I
O _
? J�dy - ml
MAILING ADDRESS, CITY, STATE, 2
FAX
rin
( ) -
WA STATE CONTRACTOR'S LICENSE k
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE k
NAME
Mpncx�cV\ V 1 uv,- 10i q
PRIMARY PHONE
S3) 771b -. vas
MAILING ADDRESS, CITY, STATE, ZIP
Sk Ll 1,5" ' "ei i4-il. AA 4 I lc 19937
FAX
RQ l "770 -C634o
NAME
�-(--\1e. vc� c c S,k
PRIMARY PHONE
253) -770- 2Z/00
MAILING ADDRESS, CITY. STATE, ZIP
y /:S �n +er �J Qty a Ilu �1831:2
FAX
( ) -
RNATE CONTACT NAME:
PRIMARY PHONES
E-MAIL
QcabSor
, 1,RyOo
kmh
NAME
C] OWNER FINANCED Tr"1
MAILING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
( 1 _
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I cert(fy 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 whe uch claim arises out of the reliance Qf the city, including its officers and employees, upon the accuracy of the
information suppl ed to the c ty as a part of is application. q
SIGNATURE: DATE
PRINT NAME: NL.A-r p S-Ve (Lq. -S�---/
Bulletin #100 — 4/21/2009 Page 1 of 4 k:\Handouts\Permit Application
of
Value of Mechanical Work $ (A COPY OF BID OR ESTIMATE MUST BE PROVIDED)
Indicate number of each type of fudure to be installed or relocated as part of this project. Do not include existing fu ores to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (Commeciai)
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate number of each type off fixture to be installed or relocated as part of this project. Do not include existing f fixtures to remain.
BATHTUBS (or 1tib /Shower Combo)
LAVS (Hand Sinks)
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen /utility)
WATER HEATERS (Eiectric)
HOSE BIBBS
SUMPS
WASHING MACHINES TOTAL F
PROJECT VALUATION WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
$ S- 9foU,cc $
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