22-101568-Permit Application-4-8-2022PERMIT APPLICATION
CITY OF
IT CENTER + 33325 8th Avenue South +Federal Way, WA 98003-6325
Federal Way 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
PIEPAIT NUMBER
TARGET DATE
SITE ADDRESS SUITE/UNIT #
I-P E TVALUATION - ZONING
ASSESSOR'S TAx(PARCEL
f C)�
�l PE OF PERMIT YJ 131618,OINtx 1�I IJhdIE31N�.1 MECHANICAL El DEMOLITION El ENGINEERING El FIRE PREVENTION
NAME OF PROJECT
V ZLjacJt
PROJECT DESCRIPTION r 0Detailed description of work to r t
be included on this permit only 9 P
_.. _ NAME,- PRIMARY PHONE
'Do, vk- VA a
PROPERTY OWNER s g0s1��'AWTpmE Z7P - AI1L
,
C6
lil{
NAME e PHONE
CLUL—
,...MAILING ADDRESS _E-MAIL
CONTRACTOR
CITY STATE ZIP FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE URI #
l
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS _ E-MAIL
CITY _ ...STATE ZIP FAX
' NAME� _... : PRIMARY PHONE
PROJECT CONTACT bi
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
Conceming this application) CITY STATE ZIP FAX
-... : _.
PROJECT FIN NAME FINANCING ❑ OWNER -FINANCED
When value is $5,000 or more : MAILING ADDRESS, CITY, STATE, ZIP PHONE
(RCW 19.27.095)
I cartify under penalty of per, br that] am the property owner or authorized agent of the property owner. I certify that to the crest
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that f 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 o, f Pederal Way as to any claim (including cysts, expenses, and attorneys' fees incurred in
the investigation and defense of such claiml, 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.
��.
SIGNATU ]BATE
PRINT
Bulletin #100 — February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application