11-100742My OF
Federal Way
COMMUNnYDEVELOPMENT SERVICES
33325 87H AVENUE SOUTH • PO BOX 9718
FEDERAL WAY. WA 98063 -9718
253 -835 -2607• FAX 253-835 -2609
www.dtuoffedemlwau.com
The followina is reauin
E RIVED
PERMIT
AWfi'CATION
FEDERAL WAIF bK'a0F
tion - an►6gcomnlete application will not be
SITE ADDRESS or � :)(D +i
ASSESSOR'S TAX /PARCEL #
LEGAL DESCRIPTION (e.g. Acme Estates, Lot 1)
TYPE OF PERMIT
PROJECT INFORMATION
SF MF CO ME EL PL DE ENO
oted. Please print legibly An ink) or type.
SUITE/IINIT #
LOT SIZE (sn
• BUILDING ❑ PLUNMING ❑ MECHANICAL
• DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed de n of ulor( included on this permit onlu)
PROJECT NAME (Name of Business or Oumer Last Narne) t L/L/ 4 " '0'N V L
PEOPLE •• •
PROPERTY
OWNER
CONTRACTOR
CONTACT
fF ,Lp 7
EXISTING USE
COMPANY NAME
�s
PRIMARY PHONE �s
( 6"3) �J�/S� Z55�Y
MAIUNG ADDRESS
31 sb"w•
CITY, STATE, ZIP
k 9yaj
COMPANY NAME
APPLICANT NAME
UFPiCE PHONE _
MAQ.WG D
7
CRY. STATE. ZIP
CELL PHONE
( -
,�
MAHING ADDRESS
CRY OF FED WAY I CENSE NUMBER TION DATE
FAX NUMBER
/
-B OF
1 /
L:63) 9016 /5;
_ L
b
CONTRACTOR'S REGISTRATION NUM BE
fmP� ad c•�d regale+ed W" each tlwo EXPIRATION DATE
- gb [ / /
0
T�YYlCG( 107'
_ 2'�'i ( Z
COMPANY NAME
APPLICANT NAME
OFFICE PHONE
MAHING ADDRESS
CITY, STATE, ZIP
CELL PHONE
RELATIONSHIP TO PROJECT
FAX NUMBER
❑ Architect ❑ Tenant
❑ Agent ❑ Other
PROPOSED USE
VALUE OF PROPOSED WORK
SPRINI1I BRED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED /REQUIRED? ❑ YES ❑ NO
WATER SERVICE PROVIDER ❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
SEWER SERVICE PROVIDER 13 I.AKEHAVEN ❑ FIIGHLINE ❑ PRIVATE (SEPTIC)
BASEMENT
FIRST
SECOND
(DESCRIBE)
FT.
MECHANICAL
Value of Mechanical Work $
AIR HANDLING UNITS
APORATWE COOLERS
GAS LOGS _
BBQS
FANS
HOODS (commeciall _-
BOILERS
FUMPLACE INSERTS
RANGES _
COMPRESSORS
FURNACES
GAS WATER HEATERS
DUCTS
GAS PIPE OUTLETS
PLVJI MG
BATHTUBS(" r C=W
SHOWERS
WATER CLOSETS nbtleq
DISHWASH
SINKS
DRINKING FOUNTAINS
GAS PIPE UTLETS
SUMPS
RAINWATER SYST
WASHIN MACHINES
URINALS
HOSE BIBBS
LAVS i,h— sm*w
VACUUM BREAKERS
ELECTRIC WATER HEATERS
REFRIG. SYSTEMS
OODSTOVES
MI (Describe)
MISC (Describe)
I certW under penalty of perjury that the h&rmation furnished by me is true and correct to the best of mU knowledge, and further, that I
am authorized by the owner of the above premises to perform the work for which the permit application is made. I further agree to hold
harmless the City of Federal Way as to any claim (including costa, expenses, and attorneys' fees incurred in the investigation and defense of
such chin), which may be made by any person, including the undersigned, andJiled against the City of Federal Way, but only where such claim
arises out of the reliance of the city, including its g0toers and employees, upon the accuracy of the inifonmation supplied to the city as a part of
this application.
NAME /TITLE DATE
(Signature) Tnue)
RELATIONSH P TO PROJECT o Owner ❑ Agent ❑ Contractor ❑ Architect ❑ Other
Bulletin #100 — January 1, 2006 Page 2 of 4 Mliandouts\Permit Application
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