12-105167CITY OF 'A
Federal W
COM SERVfgD
253-835-2607• FAX 253-835-2609
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PERMIT
APPLICATION
SF MF CO ME PL DE EN FP `
SITE ADD FEDERAL
SUITE/UNIT #
cIr� s S 32c� �
PROJECT VALUATION
ZONING
TAX/PARCEL$!�
92'1.x
7`7
2
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
TYPE OF PERMIT
❑ DEMOLITION ❑ ENGINEERING )e FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeoumer Last Name)
p4tAj1iZ P041MS , /4"Aq- �A 1
PROJECT DESCRIPTION
Detailed description of work to
/90n cfIE jirJrll w lixj' ant c t 3 irk Mme►
be included on this permit only
M-LUCC'S QJM--, flAl
NAME PRIMARY PHONE
PROPERTY OWNER
JC- y OtMA S 364- Zoo
MAILING ADDRESS E-MAIL
NX40orwdvi
CITY� STATE ZIP
�QC�
NAME
E - s'VA Eb to
MAB IN ADDRESS E-MAIL
22�
CONTRACTOR
�`
CITY w', y
STS
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W
73 �� 3 �8Y-3-7
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE #
ES s L 6 G/ 26 2-24::10-133-1-00 -&L
-S�uq-b S7rM s t - 7
&
G ADDRESS E-MAIL
APPLICANT
wa PAX
3 (tO) 11-3 Ii
PROJECT CONTACT
N,,,l �JA PH�oNE
Mie individual to receive and
MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application)
227 �' 2 s>rev►n s C
CITY
STATE
W
FAX q �y 1
/ V 3 73 G. J ) / L
ALTERNATE CONTACT NAME:
PHONE E-MAIL
PROJECT FINANCING
NAME El OWNER -FINANCED
Required value of $5,000 or more
--F
MAILING ADDRESS, CITY, STATE, ZIP PHONE
(RCW 19.27.0951
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certVy 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 a part of this application.
l YL.
SIGNATURE: J�' v ►�N. DATE
PRINT NAME: MIK'CTFfVNA4
Bulletin #100 — January 1, 2011 Page 1 of 3 kA Handouts\Permit Application
VALUE OF MECHANICAL WORK $
(a copy of bid or estimate must be provided)
Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existin fixtures to remain.
AIR HANDLING UNITS
FANS
GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS
HOODS (Commercial)
BOILERS
FURNACES
HOT WATER TANKS (Gas)
COMPRESSORS
GAS LOG SETS
REFRIGERATION SYST
DUCTING
GAS PIPING
WOODSTOVES
Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS (or 1)rb/Shower Combo) LAVS (Band S-ks) TOILETS WATER PIPING
DISHWASHERS RAINWATER SYSTEMS URINALS OTHER (Describe)
DRAINS SHOWERS VACUUM BREAKERS
DRINKING FOUNTAINS SINKS (Mb hen/urlhty) WATER HEATERS (Electric)
HOSE BIBBS SUMPS WASHING MACHINES TOTAL FIXTURES
CRITICAL ARRAS ON PROPERTY? I WATER PURVEYOR I SEWER PURVEYOR I VALUE OF EXISTING IMPROVEMENTS
EXISTING/PREVIOUS USE LOT SIZE (In Square Feet) ERISTING FIRE SPRIM" SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 -January 1, 2011 Page 2 of 3 k:\Handouts\Permit Application