09-104313CWYOF ,A
Feae I E DOPERM IT
COMYDEPEP IC
ES
253- 8352607• FAX 253 -8 35-26 09 APPLICATION
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SAF CO ME PL 6E EN' FF
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OWNER IS ALSO: ❑ CONTRACTOR ❑ APPLICANT
NAME
CONTRACTOR MAILING ADDRESS, CITY, STATE, ZIP
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
Required for projects with
value of $5, 000 or more
(RCW 19.27.095
l[S ?S 07CA19 - kLo%;; t.4-fttf tiJW uvr
WA STATE CONTRACTOR'S LICENSE N ERPDtATION DATE
NAME
MAILING ADDRESS, CITY, STATE, ZIP
NAME
MAILING ADDRESS, CITY, STATE, ZIP
ALTERNATE CONTACT NAME:
NAME
S, CITY, STATE, zip
PRIMARY PHONE
1 -
❑ PROJECT CONTACT
PRIMARY PHONE
(36 0) 6?z— 061-o
FAX
'('35o) 612--1967
FEDERAL WAY Busnvm S LICENSE N
PRIMARY PHONE
FAX
PRIMARY PHONE
FAX
E-MAH.
❑ OWNER - FINANCED
PRIMARY PHONE
L 1
I certVy 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 authorised 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 claim arcs out of the reliance of the city, including its officers and employees, upon the accuracy of the
information suppued o cit" a f t is application.
SIGNATURE: j� DATE 6 Q
�iNT NAME: Daa► OvS Q. ,DL1- t&i9SH -
Bulletin # 100 - 4/17/2009 Page 1 of 4 k:\Handouts\Petmit Application
r
MEANICAL FIXT
dw IL of Mechanical Work $ A COPY OF BID OR ESTIMATE MUST BE PROVIDED
I ic&te nu ea type fixture to be installed or relocated as part of this project. Do not include wdsting fixtures to remain_
AI AND FANS GAS PIPE OUTLETS OTHER (Describe)
ONDITION FIREPLACE INSERTS HOODS (commerciA
--- FURNACES HOT WATER TANKS (Gan)
RS_ GAS LOG SETS REFRIGERATION SYST
D GAS PIPING WOODSTOVES
j
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 sin"
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen /utiiity)
WATER HEATERS (Electric)
HOSE BIBBS
SUMPS
WASHING MACHINES TOTAL FD[TURES
GENERAL INFORMATION
PROJECT
W ER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
}VALUATION
?/ � �^
E PREVIOUS USE
LOT )In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No
❑Yes ❑ No
1 AREA DESCRIPTION Area Construction # of
�« cl -.— 1pee* Occupancy Group(s) ,�_ Additional Information
ADDITION
AREA DESCRIPTION Area Occupancy Group(s) Construction # of Additional Information
in Square Feet Tvve Stories
TENANT AREA ONLY
Bulletin # 100 — 4/17/2009 Page 2 of 4 k:\Handouts\Permit Application