12-103446error � RECEIVE
�PERMIT
Federal Way
2 50
COMMUNITY DEVELOPMENT SERVICES 2 kPPLICATION
253-835-2607• FAX 253-8 609
_u_u._;riolreueryru_a OF FEDERAL WAY
CDS
- 1 0 __3_ 4_4&
MF CO ME PL DE EN CFP
yt Q �'A
SITE ADDRESS SUITE/UNIT M
PROJECT VALUATION ZONING ASSESSOR'S TAX/ PARCEL #
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING PKFIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PO -U I�"i /�}�tJ
N APA ` �� F7- L_b� J
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PROJECT DESCRIPTION
l 1�I5 i i4l.L W 1 r1 c SS 1� If P� E. f3'J1 UD i /V 6 )
Detailed description of work to
be included on this permit only
PROPERTY OWNER
NAME
ECRUl.� 2rC5 ����./�c
PRIMARY PHONE
' 0 :5k
MAILING ADDRESS
E-KAIL
.J_) UN�S v (5t►--wc
CITY
STATE
ZIP
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I V
NAME
T1�S �I
PHONE
2G� r ql� v1
MAILING ADDRESS -7
t GV 2– 1 ��
E-MAIL
Hiq'LC_7J CL) e-1NIkS CtJL
CONTRACTOR
CITY
STATE
ZI
FAX
WA STATE CONTRACTOR'S LICENSE M
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE A
K' 1 3CT5 - C
NAME .--
PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
NAME i
)
PHONE V
2xt,, Z
MAILING ADDRESS r
' w 1 kvE N
E-MAIL
I
t'fYT L� G Jlh/ I ►I
respond to all correspondence
concerning this application)
CITY v E
fC'RYH.aYrIIAC. i/1T
VL%&f
ZIP I� o
1.
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
CvG,I�/TI�S C
PROJECT FINANCING
Required value of $5,000 or more
NAME
OWNER -FINANCED
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
1 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 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.
�l
SIGNATURE: _ DATE
PRINT NAME- �, C
Bulletin # 100 — January 1, 2011 Page i of 3 k:AHandouts\Permit Application
) , C- Lw
0
0
VALUE OF MECHANICAL WORK $ (a copy of bid or estimate must be provided)
Indicate how many of each type of frxture to be installed or relocated as part of this project. Do not include existing fbaures to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (coon—i l)
BOILERS FURNACES HOT WATER TANKS JG-)
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 furfures to remain.
BATHTUBS )or Tab/shower combo)
LAVS lHand Sinks)
TOILETS WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen/uta;ry)
WATER HEATERS (El—n-w)
HOSE BIBBS
SUMPS
WASHING MACHINES TOTAL FIXTURES'
TENANT AREA ONLY
CRITICAL AREAS ON PROPERTY? WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
EXISTING/PREVIOUS USE LOT SIZE l/n Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes [ i No ❑ Yes ❑ No
AREA DESCRIPTION Area
in Square Feet
Occupancy Group(s) Construction # of Additional Information
Type I Stories
ADDITION
AREA DESCRIPTION Area
Occupancy Group(s)Construction # of Additional Information
in Square Feet
Stories
Type7777
TOTAL BUILDING
-
TENANT AREA ONLY
PROJECT AREA ONLY
'x
Bulletin tr 100 Ianuary I, 101 1 Page 2 of 3 k:UHandouts\Permit Application