12-104352 cirroF RECEIVE. I Z - 0�. 5-2.
Federal Way PERMIT MF CO ME PL DE EN FP
COMMUNT1Y DEVELOPMENT SERV&P 2 4 201AP P LI CAT I O N
253-835-2607•FAX 253-835-2609
n uu.c(lyoJtedern(m`+AIT OF FEDERAL WAY
CDS
SITE ADDRESS SUITE/UNIT#
34410 16th Ave S 103
PROJECT VALUATION ZONING ASSESSORS TAX/PARCEL#
$ 2 , 500 . 00 2 5 0 0 9 0 _ 0 0 4 0
TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING ZI FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name) Bella Dental
Add 20 pendent for sprinklers
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER Federal Way Market Place
MAILING ADDRESS E-MAIL
5743 Corsa Ave #216
CITY STATE ZIP
Westlake Village CA 91362
NAME PHONE
Fire Sprinklers Incorporated 253-826-0099
MAILING ADDRESS E-MAIL
CONTRACTOR
1524 45th St E Suite 102 Gregr�firesprinklersinc.com
CITY Sumner STATE
ZIP 98390 FAX 253-826-1033
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
FIRESI*988RJ 12 /31 13 20-05-100633-00-BL
NAME Fire Sprinklers Incorporated PHo253 -826-0099
APPLICANT MAILING ADDRESS E-MAIL
1524 45th St E Suite 102 Ken@firesprinklersinc.com
CITY STATE ZIP FAX
Sumner WA 98390 253 -826-1033
PROJECT CONTACT
PHONE
Ken Long 253 -826-0099
(The individual to receive and
respond to all correspondence MAILING ADDRESS E-MAIL
concerning this application) 1524 45th St E suite 102
CITYST ZIP FAX
Sumner 98390 ken@firesprinklersinc.com
ALTERNATE CONTACT NAME: PHONE E-MAIL
Greg Moffett 826-0099 greg@firesprinklersinc.com
PROJECT FINANCING NAME
❑ OWNER-FINANCED
Required value of$5.000 or more
(RCW 19.27.095) MAILING ADDRESS,CITY,STATE,ZIP PHONE
I certify 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 wilt 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.
SIGNATURE: — iZv DATE /G y/L c f L
PRINT NAME: Ken Long
Bulletin#100—January 1,2011 Page I of3 k:AHandouts\Permit Application