16-104561TO
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CITY OF '�:
Federal Way SEP 13 2016
CITY OF FEDERAL WAY
PERMIT NUMBER / L / 0 § �3 (' /
PERMIVAPPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003 -6325
253 - 835 -2607 + FAX 253 - 835 -2609 + permitcenter (acityoffederalway.com
1
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L TARGET DATE
SITE ADDRESS
X314 5vl 3�) tom St- .
SUITE /UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX /PARCEL #
$ 3a45,�
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
YD!)VI 05K 1- 2 Ce41-C4
R h W Qv,, T T_ - R C 1 O CGt v c 6WJ
PROJECT DESCRIPTION
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Detailed description of work to
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U i . e
be included on this permit only
NAME %
�
PRIMARY HONE
,
PROPERTY OWNER
MAILING ADDRESS
�1
CITY 1'
STATE
ZIPS '3V 7 �
F2F
PHONE
I--:v a•I,;a?
MAiLHfG ADDRESS
E -MAIL
CONTRACTOR
CITY
�FN1
3T T
.��rZ
ZIP
`d032
FAX
2oiv� ?50 1';tj
WA
A C NTRA
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EXPIRATION DATE
0-1 AT
FEDERAL WAY BIISIIfE88 LICENS
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NAME j� {� j� y� �i� j �i/
VAN 1 I( 0' U 'v�i -► J 1 w✓ J� 1 l S S
�PRLIARY PHONE !/ 7 150 Z
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NAMING ADDRESS D� c L
E- ��� n �� &s
APPLICANT
CITCCY[� V & 1
BTA
�1�
ZIP
, 3 Z,
FAX
_961V 4
NAME
�A I
PRIMARY PHONE
PROJECT CONTACT
1 7 ► V f��� --
MAILING ADDRESS <
E -MAIL
(The individual to receive and
respond to all correspondence
5 of_'
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
El OWNER-FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
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 apart of this application.
g � ` � Ally-
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SIGNATURE .ill DATE
PRINT NAME: VATif I d ' R-C A P- F&_ � -1 W �5T FI (Ze--
Bulletin #100 — January 29, 2016
Page 1 of 2
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