12-105391c,rOF ARECEI V ED
Federal Wlyv 2 9 2012 PERMIT
COMMUNITY DEVELOPMENT SERVICES �PLICATION
253 - 835- 2607•FAX 253 - 835 -2609 l�erRTttA
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SF MF CO ME PL DE ENfp
LDS n in rr))r At r-,
SITE ADDRESS G �+ f
SUITE/UNIT S
PROJECT VALUATION
ZONING
ASSESSOR'S TAX /PARCEL fl ' 0 - J
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
/
t�1 C� 2
PROJECT DESCRIPTION
Detailed description of work to
/ / n° r c- i ei-
be included on this permit only
PROPERTY OWNER
NAME / . /� / /
1'RIINliRY PHONE
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME // �e,�
PHONE
MAILING ADDRESS
CONTRACTOR
ZIP���
FAX
NTRG / AyCam TO /IIj'LCf I/CE,N LICENSE
TO/ j ;Wl
WAY `LICE Sak
V Nf
NAME
/ /
PHONE
MAILING ADDRESS
E -MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
respond to all Correspondence
MAILING ADDRESS
E-MAIL
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
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certfy 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 where such claim ut of iance of the city, including its officers and employees, upon the accuracy of the
information supplied to a city as t o cation,
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 - January 1, 2011 Page I of 3 k:\Handouts\Pemtit Application
/ 61� a'4
! •
VALUE OF MECHANICAL WORK $
BATHTUBS forTbb /Sho —r Combo)
(a copy of bid or estimate must be provided)
Indicate how many of each o
Wbc-inStalled or relocated as part of this project. Do not include extsting f xtures to remain.
AIR HANDLING UNITSr
FANS
GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS
HOODS (Commrr ial)
BOILERS
FURNACES
HOT WATER TANKS (Gas)
COMPRESSORS
GAS LOG SETS
REFRIGERATION SYST
DUCTING
GAS PIPING
WOODSTOVES
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS forTbb /Sho —r Combo)
LAVS (Hand Sinks)
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (wirhrn /UUrcy)
WATER HEATERS (urrino
HOSE BIBBS
SUMPS
WASHING MACHINES TOTAL FIXTURES
AREA DESCRIPTION Area
in Square
ADDITION
AREA DESCRIPTION I Area
in Square
TENANT AREA ONLY
Construction I # of
Occupancy Group(s) I r—e c +--I-. I Additional Information
Occupancy Group(s)
# of Additional Information
Stories
Bulletin #100 -January 1, 2011 Page 2 of 3 k:\Handouts \Permit Application