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12-102264C -� �,r� �EIVED PERMIT Federa COMMUNITY D E VELOP M2 �253 - 835 -2607d 3 -26# 2 202 APPLICATION w w w. cit u o X al wa u. com CITY OF FEDERAL WAY rnq '!�_ - .1Qa g1 SF MF CO ME PL DE EN P SITE ADDRESS SUITE /UNIT # Q PROJECT VALUATION ' ZONING ASSESSOR'S TAX /PARCEL # TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION NAME OF PROJECT (Tenant Name /Homeowner Last Name)��/ // JT-GG C��IG Gt/G i d G��S PROJECT DESCRIPTION Detailed description of work to X/ s ti,75 'e c t'ce c✓ �► 0���/ C4 be included on this permit only NAME ` PRIMARY PHONE PROPERTY OWNER MAILING ADD E -MAIL CITY I S A ZIP NAMEl�� VZ L f PHONE MAILING ADD 2ag d el CONTRACTOR CI Gym � ate/ WA STATE CONTRACTOR'S LICENSE # 'f l % G� XPIRATION DATE / / FEDE WAY BUSINESS LICENSE # da GO _17220 NAME PHONE APPLICANT MAILING ADDRESS E -MAIL CITY STATE ZIP FAX PROJECT CONTACT NAME PHONE (The individual to receive and MAILING ADDRESS E -MAH, respond to all correspondence concerning this application) CITY ST E ZIP FAX ALTERNATE CONTACT NAME: PHONE E-MAIL PROJECT FINANCING NAME OWNER - FINANCED Required value of $5,000 or more (RCW 19.27.0951 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 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 SIGNATURE: DATE 2 C / r PRINT NAME: L/ Bulletin #100 —January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application r?/1