09-103422ECEIVE#
ctrOF PERMIT
Federal Wd*P 0 3 2009
COMMUNITY DDEVELOPMENT SERVICES 1 M
LI CATI O N
253 T -, i DER
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SF MF CO ME EL PL DE EN
I cert{Jy 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 the city as apart of this application.
SIGNATURE: DATE 15�jv
PRINT NAME: ft-,r&fP A
Bulletin #100 - 4/21/2009 Page 1 of 4 k:\Handouts\Perniit Application
Value of Mechanical Work $
(A COPY OF BID OR ESTIMATE MUST BE PROVIDED)
Indicate number of each type offtirture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
AIR HANDLING UNITS
FANS
GAS PIPE OUTLET'S OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS
HOODS (comm —isa)
BOILERS
FURNACES
HOT WATER TANKS (G..)
COMPRESSORS
GAS LOG SETS
REFRIGERATION SYST
DUCTING
GAS PIPING
WOODSTOVES
1111FEIN 7-77
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J F
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 Sinks)
TOILET'S
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
L�o
DRINKING FOUNTAINS
SINKS (IDtchenmulity)
WATER HEATERS (E)..tric)
$
HOSE BIBBS
SUMPS
WASHING MACHINES
EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
1111FEIN 7-77
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PROJECT VALUATION
WATER PURVEYOR
SEWER PURVEYOR
VALUE OF EXISTING IMPROVEMENTS
-1)
L�o
$
EXISTING/PREVIOUS USE
LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
OYes ❑
No ❑ Yes ❑ No
Bulletin #100 – 4/21/2009 Page 2 of 4 kAl-landoutsTertnit Application