03-1025421
City of Federal Way
Community Development Services Mechanical Permit #:03 -102542 - 00 - ME
33330 1st Way S
Federal Way, WA 98003-6210
Ph: 253.661.4000 Fax: 253.661.4129 Inspection request line: 253.835.3050
Project Name: BERGSTROM
Project Address: 32033 16THrSW Parcel Number: 010450 0420
Project Description: Gas water heat r installation and gas piping leak repair.
Owner
Applicant
Contractor
Thomas S Bergstrom & Deanna Joy Bergstrom
PAT'S PLUMBING
NONE
32033 16TH PL SW
PAT'S PLUMBING
FEDERAL WAY WA
PO BOX 4447
98023-5415
FEDERAL WAY WA 98063
I hereby certify that the
the occupancy and the u
the City of Federal Wa
Owner or agent:
All
6 1- 1 't —V 3 h & A --.el
PU
Ak RECEIVE® CONSTRUCTION PERMIT APPLICATION
CITY OF 8 4%
�� PPLICATION NUMBER: -
Fe d e ra l Way JUN 2 0 Z00[APPLICATION NUMBER:
CITY OF FEDERAL WAY PPLICATION NUMBER:
"The followil�, N-&*aArhfTTbtmation — Please print (in ink) or type**
Please note: Electrical. Fire Prevention Systems and Engineering permits may require a separate application.
SITE ADDRESS: J 3 1 " �k �t �j W ASSESSOR'S TAX/PARCEL #:
Oto
LEGAL DESCRIPTION OF SUBJECT PROPERTY (ATTACH SEPARATE DESCRIPTION IF LENGTHY): j•` -Y
■ PR03ECT INFORMATION
TYPE OF PROJECT (This application): o BUILDING o PLUMBING(MECHANICAL o DEMOLITION
o ELECTRICAL o ENGINEERING o FIRE PREVENTION SYSTEM
PROD�CoT DESCRf PTION (Prot a detailed description): a I ru
E,gh�K r �X ( --t-u r y "",11,_
PROJECT NAME:
PROPERTY OWNER: N E: i DAYTIME PHONE'
MAILIN DRESS (STREET ADD ESS; CITY, STATE, Z ):
J1 `(gel S L. QI G U 2
CONTRACTOR: NAM
DAYTIME PHONE:
-{S P(Vt��I`� (✓�c. (2-53) -519111
MAILING ADDRESS (STREET ADD SS; cn*- wat IP : I. EVENING PHONE-
�(5� (M (I�tar� S Pr�c ate, \A CITY OF OF F DERAL WAY BUSIWM LICENSE NUMBER:I �.� ......o��
APPLICANT:
LCONTRACTOR'S REGISTRATION NUMBER: Q /► '{ �C ,�j� p, I EXPIRAT(I[OiN DATE' Q
(copy of card required) - A- 1 1 '! 1!L Ll 5 i � -/ ! �
ADDRESS (STREET ADDRESS; CITY, STATE,
DAYTIME PHONE:
) 1
EVENING PHONE:
)
RELATIONSHIP TO PROJECT: 1 FAX NUMBER:
o ARCHITECT o TENANT o OTHER ( DESCRIBE):
E-MAIL ADDRESS: I
` l/ I
CONTACT PERSON FOR THIS PROJECT: o PROPERTY OWNER o APPLICANT L,pNTRACTOR
• • • • /•
EXISTING USE: EXISTING BUILDING ASSESSED/APPRAISED VALUATION $
PROPOSED USE: PROPOSED VALUATION FOR IMPROVEMENTS: ;
SPRINKLERED BUILDING? o YES o NO FIRE SUPPRESSION SYSTEM PROPOSED/ REQUIRED: o YES o NO
WATER SERVICE PROVIDER: o LAKEHAVEN o HIGHLINE o TACOMA o PRIVATE (WELL)
SEWER SERVICE PROVIDER: o LAKEHAVEN o HIGHLINE 0 PRIVATE (SEPTIC)
V, .
**NEW RESIDENTIAL CONSTRUCTION ONLY**
NUMBER OF BEDROOMS: ESTIMATED SELLING PRICE: $
PROJECT••• AREAS
FLOOR
EXISTING SQ. FT.
PROPOSED SQ. FT.
TOTAL
BASEMENT
Indicate number of each type of fixture
FIRST
AIR HANDLING UNITS)
SECOND
GAS LOG(S)
REFRIG. SYSTEM(S)
BBQ(S)
THIRD
HOOD(S)
WOODSTOVE(S)
BOILERS)
FOURTH
RANGE(S)
MISC.
COMPRESSOR(S)
OTHER FLOORS (DESCRIBE)
HEAT SOURCE:
ELECTRIC
DUCT(S)
DECK
❑
GARAGE
HOW MANY F ?
(FAS
BATHTUB(S)
TOTAL:
URINAL(S)
WATER HEATER(S)
DISHWASHER(S)
]TSCLATMFR/SIGNATURE SLC
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 aim arises out of the reliance of the city, including its officers and employees, upon the accuracy
of the information sup i to e ty as a part of this application.
NAME/TITLE: DATE: % 3
' ,rye, W xrG t
❑ PROPERTY OWNE•, PLICANT �'>iwCONTRACTOR Z
COMMUNITY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063-9718 • 253-661-4000 • FAX: 253-661-4129
www.ciboffederalway.com
FIXTURES
Indicate number of each type of fixture
MECHANICAL
AIR HANDLING UNITS)
EVAPORATIVE COOLER(S)
GAS LOG(S)
REFRIG. SYSTEM(S)
BBQ(S)
FAN(S)
HOOD(S)
WOODSTOVE(S)
BOILERS)
FIREPLACE INSERTS)
RANGE(S)
MISC.
COMPRESSOR(S)
FURNACE(S)
OUTLET(S)
HEAT SOURCE:
ELECTRIC
DUCT(S)
GAS PIPE
❑
PLUMBING
(FAS
BATHTUB(S)
LAVATORY(S)
URINAL(S)
WATER HEATER(S)
DISHWASHER(S)
RAIN WATER SYS.
VACUUM BREAKER(S)
❑ ELECTRIC ❑ GAS
DRINKING FOUNTAIN(S)
SHOWER(S)
WASH MACHINE OUTLET
GAS PIPE OUTLET(S)
SINKS)
WATER CLOSET(S)
MISC.
INTERCEPTORS)
SUMP(S)
]TSCLATMFR/SIGNATURE SLC
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 aim arises out of the reliance of the city, including its officers and employees, upon the accuracy
of the information sup i to e ty as a part of this application.
NAME/TITLE: DATE: % 3
' ,rye, W xrG t
❑ PROPERTY OWNE•, PLICANT �'>iwCONTRACTOR Z
COMMUNITY DEVELOPMENT SERVICES • 33530 FIRST WAY SOUTH • PO BOX 9718 • FEDERAL WAY, WA 98063-9718 • 253-661-4000 • FAX: 253-661-4129
www.ciboffederalway.com