02-103238City of Federal Way
Community Development Services Mechanical Permit #:02 - 103238 - 00 - ME
33530 lst Way S
Federal Way, WA 98003-6210
Ph: 253.661.4000 Fax: 253.661.4129 Inspection request line: 253.835.3050
Project Name: DERROW
Project Address: 33420 35TH SSW Parcel Number: 109960 0180 j%
Project Description: MEC - Replace gas water heater
Owner
Applicant
Contractor
Bertha L Derrow
NORDIC HEATING, INC.
NORDIC HEATING, INC.
33420 35TH AVE SW
3411 C ST. NW BAY 8
3411 C ST. NW BAY 8
FEDERAL WAY WA
AUBURN WA 98002
AUBURN WA 98002
98023-2968
(253) 931-0503
Mechanical Valuation..........................................485 Over the Counter Permit...................................... Yes
PERMIT EXPIRES January 26, 2003, IF NO WORK IS STARTED.
Permit issued on July 30, 2002
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and the use wil be in accordance with the laws, rules and regulations of the State of Washington and
the City of Federal Way.
Owner or agent: L� !G'L' Date:
-a
CONSTRUCTION PERMIT APPLICATION
N> Fy APPLICATION
APPLICATION NUMBER:
PPLICATION NUMBER:
**The following is required information — Please print (in ink) or type**
Please note: Electrical, Fire Prevention Systems and Engineering permits may require a separate application.
SITE ADDRESS: C �j � S�V� ASSESSOR'S TAX/PARCEL #: -
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY):
PR03ECT INFORMATION--:
TYPE OF PROJECT (This application): ❑ BUILDING ❑ PLUMBING VrMECHANICAL ❑ DEMOLITION
❑ ELECTRICAL ❑ ENGINEERING❑ FIRE PREVENTION SYSTEM
PROJECT DESCRIPTION (Provide detailed description):
PROJECT NAME:
P'ftPERTY OWNER:
I�
CONTRACTOR:
APPLICANT:
0
NAME: IDC / Li LL)
DAYTIME PHONE:
RAILING AL/D/D)RESS (STREET ADDRESS; QTY, STATE, ZIP): ) _
4'
NAME:
DAYTIME PHONE:
MAILING ADDRESS (STREET ADDRESS; CITY, STATE, ZIP):
.�
EVENING PHONE:
"5/4t�;
t ) -
CITY OF FEDERAL WAY BUSINESS LICENSE NUMBER:
FAX NUMBER:
CONTRACTOR'S REGISTRATION NUMBER:
IXPIRATION DATE:
(copy of card required) l
h- l . J
/ l `� 1 t
NAME:
MAILING ADDRESS (STREET ADDRESS; CITY, STATE, ZIP):
RELATIONSHIP TO PROJECT:
❑ ARCHITECT ❑ TENANT ❑ OTHER( DESCRIBE):
CONTACT PERSON FOR THIS PROJECT: ❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
DAYTIME PHONE:
V��) cl-5/
EVENING PHONE:
)
FAX NUMBER:
)
E-MAIL ADDRESS:
DETAILED BUILDING INFORMATION
EXISTING USE: EXISTING BUILDING ASSESSED/APPRAISED VALUATION
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS:,
SPRINKLERED BUILDING? ❑ YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED/REQUIRED: ❑ YES ❑ NO
WATER SERVICE PROVIDER:
SEWER SERVICE PROVIDER:
❑ LAKEHAVEN ❑ HIGHLINE ❑ TACOMA ❑ PRIVATE (WELL)
❑ LAKEHAVEN ❑ HIGHLINE ❑ PRIVATE (SEPTIC)
**NEW RESIDENTIAL CONSTRUCTION ONLY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE:
- ■ PR03ECT FLOOR AREAS
FLOOR
EXISTING SQ. FT.
PROPOSED SQ. FT.
TOTAL
BASEMENT _
FIRST
SECOND
THIRD
FOURTH
OTHER FLOORS (DESCRIBE)
DECK
GARAGE
HOW MANY FLOORS?
TOTAL:
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNIT(S) EVAPORATIVE COOLER(S) GAS LOG(S) REFRIG. SYSTEM(S)
BBQ(S) FAN(S) HOODS) WOODSTOVE(S)
BOILERS) FIREPLACE INSERTS) RANGE(S) MISC. ( )
COMPRESSOR(S) FURNACE(S)
DUCT(S) GAS PIPE OUTLET(S) HEAT SOURCE: ❑ ELECTRIC ❑ GAS'
PLUMBING / �SOP
BATHTUB(S) LAVATORY(S) URINAL(S) WATER i6AS
ER(S)
DISHWASHER(S) RAIN WATER SYS. VACUUM BREAKER(S) 1:1 ELECTRIC
DRINKING FOUNTAIN(S) SHOWER(S) WASH MACHINE OUTLET
GAS PIPE OUTLET(S) SINKS) WATER CLOSET(S) MISC. ( )
INTERCEPTOR(S) SUMP(S)
]TSCLOTMERMYGNOTURE BLC
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge, and
further, that I am authorized by the owner of the above premises to perform the work for which the permit application is made. 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 of
Federal Way, but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy
of the information su lied to the city as a part of this application.
NAME/TITLE.��Z� �1,�/-�,— DATE:
❑ PROPERTY OWNER ❑ APPLICANT ❑ CONTRACTOR
COMMUNM DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063-9718 • 253-6614000 • FAX: 253-661-4129
www.ckwffederalway.com
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DEPARTMENT OF LABOR AND INDUSTRIES
'
REGISTERED AS PROVIDED BY LAW AS
I
CONST CONT GENERAL
REGIST". #EXP. DATE
CC01 NORDIHI099BJ 01/09/20014
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EFFECTIVE DATE =01/11/1991'
#
NORDIC HEATING INC
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3411 C ST NE BAY 8
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AUBURN WA 98002
F025-052-000 (8/97)
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