09-104651cm or
Fed IVE® *PERMIT
COMMU8Y17YDEVELOP6EIYT SERVICES
APPLICATION 253 n3
u5.dor2 G J 2 0 g
l 6 -G S(
10- -ME--EL PL DE E11d A
SITE ADDRESS
72.0 `A69sst
SUITE/UNIT # ZONING ASSESSOR'S TAR /PARCEL #
A —I.4 23 �_( '4
NAME OF PROJECT ��}}
(Tenant or Homeowner Name) W
❑ DEMOLITION ION ❑ ELUF�CTRICAL
TYPE OF PERMIT "
ERINC� �I$E„ VENTION
Detail( 6
PROJECT DESCRIPTION Subje t to attached
Detailed description of work to
be included on this permit only _-
NAME / ', PRIMARY PHONE
PROPERTY OWNER w ( ) -
MAILING ADDRESS, CITY, STATE, ZIP WMAIL
OWNER IS ALSO:
13 CONTRACTOR APPLICANT [3 PROJECT CONTACT
NAME / � � �
PRIMARY PHONE
FAX
CONTRACTOR
MAILING ADDRESS, CITY, STATE, ZIP
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
�1J1
NAME
S� -bra 55" [
"
PRIM4RY PHONE
� �
Z4 - (q q!;
APPLICANT
MAILING ADDRESS, CITY, STATE, ZIP
1607 e6 �± kf, Nv,--
i
We,
FAX
�D3 - 2D
PROJECT CONTACT
NAME p
9V05 � 8 9
PRIMARY PHONE
z�-1
(The individual to receive and
'f
- i44S
MAILING ADDRESS, CITY, STATE, ZIP
m o I +p �e 41N6 WiL 1'&a7-3
FAX
u) t.�b'5 -1 O�
respond to all correspondence
concerning this application)
ALTERNATE CONTACT N"AM"E:
PRIMARY PHONE
E -MAIL
re�exr z�
PROJECT FINANCING
NAMEr
OWNER - FINANCED
Required for projects with
N
MAILINh ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
value of $5, 000 or more
(RCW 19.27095)
-
I certify under penalty of perjury that Z am the property owner or authorized agent of the property owner. Z cert(jy that to the
best of my knowledge, the information submitted in support of this permit application is true and correct. I certify that Z will comply
with all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. Z 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.
Z 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 flied 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
i>formation supplied to the city as apart of this application. SIGNATURE: DATE t 1 ZS 09
PRINT NAME:
Bulletin #100 - 4/17/2009 Page 1 of 4 k:\Handouts\Permit Application
MKIIANICA L
Value of Mechanical Work $ (A 0
Indicate number of each type of fixture to be installed or relocated as
AIR HANDLING UNITS FANS
_ AIR CONDITIONER FIREPLACE INSERTS
_ BOILERS FURNACES
_ COMPRESSORS GAS LOG SETS
DUCTING GAS PIPING
XTOWW
OF BID OR ESTIMATE MUST BE PROVIDED
of this project. Do not include existing fixtures to remain.
GAS PIPE OUTLETS OTHER (Describe)
HOODS (commercial)" I
HOT WATER TANKS (caa)
_ REFRIGERATION SYST
W OODSTOVES
GENERAL INFORMATION
PLFIN
FIXTITR
Indicate number of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS (or Tub /shower combo(
LAVS (Hand Si.]*
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen /utility)
WATER HEATERS (Electric)
HOSE BIBBS
SUMPS
WASHING MACHINES TOTAL FIXTURES
GENERAL INFORMATION
O"= VALUATION
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF ERISTING IMPROVEMENTS
5
ERI
LOT SIZE (In Square Feet(
E%ISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
❑ Yes ❑ No
TENANT AREA ONLY
PRO.IECT AREA ONLY
Bulletin # 100 — 4/17/2009 Page 2 of 4 k:\Handouts\Permit Application