16-100787 RECEIID (.1
�r,aF FEB i 1 2016 P •
ERMIT APPLICATION
Federal Way
CITY OF FEDERAL WAY
/ CDS
PERMIT NUMBER / /_ - / 0 o 7 y 2- FP
111��� ` TARGET DATE
SITE ADDRESS SUITE/UNIT#
3 (ID. CA/c�r,�>Jrc--� `?icwy 5 51 Sv3
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ _\- `� . - Ck - � � �
3/ .S 0 cf'
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION 0 ENGINEERING FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION 2c t�ov[= \� S Mc,j r% rG-raL1v0R. --C244-e--4.-
PROJECT
Detailed description of work to �Xi STIA/(. [-—r 2.. F-/az., �C-!}./j.,� ?/41-Aa---(-
be
included on this permit only
LC//7-4 .A/A-'�✓ 5-7dc6 fr//1.e� .4L.9-R-.�t 7/1-ve-'2-
NAME PRIMARY PHONE
PROPERTY OWNER F(\�(\ C L%iJ \V NY C-A-0SSt�co /2?
MAILING ADDRESS E-MAIL
1_G 5 _ A/L 4-1-T-4=. S'V S�\TC' 7 066
CITY STATE ' ZIP
3rz.c.wC.)6 LJ 9 `64) (I
NAME
PHONE
r,{Z� SySTel'IS wE-s-1 1 253- %33- lx.—f.&
MAILING ADDRESS E-MAIL
CONTRACTOR -c/aC.o F- 2-OS'1T Q ±t e_
CITY STATE ZIP FAX
?rte-.XCAL
LP `'1`645417
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
Ftac �ta\td{�LW Co , ,c, / ico r9-`b7 c�' i-c aL
NAME PRIMARY PHONE
50..(v\E" P C�,l..T2Ac-Tn(Z
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT )‘'\ 1T CiA(LLwvta,i.) a53-CIS\-( c4e3cbs
MAILING ADDRESS
(The individual to receive and E-MAIL
respond to all correspondence Sr\r E '(AS CcNt iL\c.' (Z, t11 Q C\ S�, L--„� 0rT,
concerning this application) CITY STATE ZIP FAX C C-
LIPI
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$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 ou of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the c'y as'.rt of this application.
SIGNATURE: DATE 2///e.,
PRINT NAME: / --7447 A/LL.oi AA/
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application