10-100847F
MAR 0 ;3 2010
Federal Way FERMIT
co2M5M3UN�
hXPPLICATION
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SF MF CO ME EL PL DE E FP
SITE ADDRESS
_§R =UNIT # ZONINA ASSESSOR'S TAX /PARCEL #
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NAME OF PROJECT
(Tenant or Homeowner Name)
TYPE OF PERNIIT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
OWNER IS ALSO:
CONTRACTOR
APPLICANT
AM'
• BUILDING ❑ PLUMBING ❑ MECHANICAL
• DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING 01;;E PREVENTION
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MAILING ADDRESS. CITY STATE, ZIP
CONTRACTOR
NAME
ef
r) 'APPLICANT
T`(Taa-1 T0,J 15 ",
WA STATE CON CTOR -S LICENSE i
atk5w 10�S 0
NAME I_
5/4 -W�'e Q5 CW��L
MAILING ADDRESS, CITY, STATE, ZIP
PROJECT CONTACT NAME
(The individual to receive and " cvw\.e el"
respond to all correspondence MAILING ADDRESS, CITY, STATE, ZIP
concerning this application)
i
PRIMARY PHONE
c ) —
E -MAIL
PROJECT CONTACT
PRIMARY PHONE
9901 - (273)Vr- oils
TION DATE FEDERAL WAY BUSINESS LICENSE #
A /11
PRIMARY PHONE
FAX
PRIMARY PHONE
FAX
:RRN,ATE CON CT NAME: PRIMARY PHONE ` tMr,L
cam
1
PROJECT FINANCING NAME
OWNER FINANCED
Required for projects with
value of $5,000 or more MAILING ADDRESS, CITY, STATE, ZIP PRIMARY PHONE
(RCW 19.27.095) )
v
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. 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 arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to t tty as apart of this application. /
SIGNATURE: DATE G
PRINT NAME:
Bulletin #100 — January 1, 2010 Page 1 of 4 k:\Handouts\Permit Application
.d. taw.,
Value of Mechanical Work $ (A COPY OF BID OR EST MATE MUST BE PROVIDED)
Indicate number of each type of Uture 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 (Commemia0
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
Indicate number of each type ofjixture to be installed or relocated as part of this project. Do not include existingfixtures to remain.
BATHTUBS (or7Lb /shower Combo)
LAVS (stand sinks)
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Khchen /Ufility)
WATER HEATERS (Ek,anr)
HOSE BIBBS SUMPS WASHING MACHINES TOTALFI7CTIIREB s
GENERAL INFORMATION
PROJECT VALUATION WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
$ �- $
EXISTING/PREVIOUS USE LOT SIZE (In Square Feet) EXISTING FIREjINXLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
Yes ❑ No Fryes ❑ No
G( 1V 2CIAL, - NEW/ADDITION
AREA DESCRIPTION Area Construction # of
in Square Feet Occupancy Group(s) Type Stories Additional Information
NEW BUZDMG
Bulletin #100 — January 1, 2010 Page 2 of 4 k:\,Handouts\Permit Application