09-102510C°' °F : PERMIT .MF C ME EL PL DE EN FP
Federal Way JUL 0 ` ®ut 1i Re�cue�"�J
comrmun�rrDt��sv FEpICATION s Detailed A
253 835 -2607• FA d� �
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
, 1
AvG ADDRESS, CITY, STATE, ZIP
Q) c)' 1i3C
❑ CONTRACTOR
ADDRESS, CITY, STATE, ZIP
WA STATE CONTRACTOR'S LICENSE #
i'j ona rJ0 4-0(o �t D
NAME _
MADdNG ADDRESS, CITY, STATE,
:ks mo,res 99)9
❑ APPLICANT
t e L
ERPMATION DATE
V. PU
MAILING ADDRESS, CITY, STATE, ZIP
5Qme, QS akzV1Z1-
ALTERNATE CONTACT NAME:
r^1 1 ^t - i _.
NAME
MAILING ADDRESS, CITY. STATE, ZIP
PRIMARY PHONE
PRIMARY PHONE
E-MAIL
❑ PROJECT CONTACT
PRIMARY PHONE
FAR
-
FEDERAL WAY BUSINESS LICENSE #
PRIMARY PHONE
1770 -.9Wa
FAX
7� - ob.3so
PRIMARY PHONE
FAX
E-MAIL
❑ OWNER - FINANCED
PRIMARY PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certVy 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 such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
irformation suppli t0 the cityras a part of this application. 1
SIGNATURE: °D `' DATE ! -07
PRINT NAME: ►�F i 1 C��1�
Bulletin #100 - 4/21/2009 Page 1 of 4 k:\Handouts\Pelmit Application
Value o Mechanical Work $ (A COPY OF BID OR ESTIMATE MUST BE PROVIDED)
Indicate number of each type of facture 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
Indicate number of each type c
BATHTUBS (orThb /Shower Combo)
DISHWASHERS
DRAINS
DRINKING FOUNTAINS
HOSE BIBBS
to be installed or relocated as
_ LfiVS (Hand Sinks)
_ RAINWATER SYSTEMS
SHOWERS
SINKS (Kitchen /Utatty)
SUMPS
this project. Do not include
TOILETS _
URINALS _
VACUUM BREAKERS
WATER HEATERS Wrrtdc)
WASHING MACHINES
I fudures to remain.
WATER PIPING
OTHER (Describe)
PROJECT VALUATION WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
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\Pemiit Application