12-100176CITY or -
:Federal Way
COMMUNITY DEV ELOPME NT SERVICES
259 835 -2607 FAX 253-83S-2609
12-- rd0( -76_
WERMIT CO ME PL DE EN FP
APPLICATIO9ECEZVED
SITE ADDRESS JAN I I Ull
SUITE /UNIT 1
54-
G
PROJECT VAL ATION
ZONING
ASSESSOR'S T L
$
CDS
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name / Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME (� 7
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
NAME
, -) k
z C-
PHONE
2 5
MAILING ADDRESS
D s It
E -MAIL
CONTRACTOR
CITY
STATE
—'kZ'22k
ZIP
FAX
✓/
O
WA STATE CONTRACTOR'S LICENSE N
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE A
PY
NAME
PHONE
-2 < n
MAILING ADDRESS /
E -MAIL
APPLICANT
CITY
STATE
21P
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
c
—
MAILING ADDRESS
E -MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
NAME
OWNER- FINANCED
Required value of $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 79.27.095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. 1 certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application.
/ �7
SIGNATURE: DATE
PRINT NAME:
Bulletin #100— January 1, 2011 Page I of 3 k:AHandouts \Permit Application
6 A-%
0 0
VALUE OF MECHAMCAL WORK r$
Indicate how many of each type of fixit
AIR HANDLING UNITS _
AIR CONDITIONER _
BOILERS
COMPRESSORS _
DUCTING
Indicate how many of each typf
BATHTUBS tot Tub/Sh— combo)
DISHWASHERS
DRAINS
DRINKING FOUNTAINS
HOSE BIBBS
CRITICAL AREAS ON PROPERTY?
EXISTING/PREVIOUS USE
re to be installed or relocated as
_ FANS _
_ FIREPLACE INSERTS _
_ FURNACES _
_ GAS LOG SETS _
GAS PIPING
to be installed or relocated as
LAVS )Hand sinks) _
RAINWATER SYSTEMS _
SHOWERS _
SINKS )Kitchen /uti&y) _
SUMPS
WATER PURVEYOR
LOT SIZE (ln Square Feet)
bid or estimate must be provided
art of this project. Do not include
GAS PIPE OUTLETS _
HOODS c..ro riaq
HOT WATER TANKS )Gas)
REFRIGERATION SYST
WOODSTOVES
Do not include
TOILETS
URINALS
VACUUM BREAKERS
WATER HEATERS (Electric)
WASHING MACHINES
g fixtures to remain.
OTHER (Describe)
Tg fixtures to remain.
WATER PIPING
OTHER (Describe)
SEWER PURVEYOR I VALUE OF EXISTING IMPROVEMENTS
EXISTING FIRE SPRINKLER SYSTEM? I PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 — January 1, 2011 Page 2 of k:AHandouts \Permit Application