10-105453RECEIAND
PERMIT
EC 3 4 2,C,
COMMUNITY DEVELOPMENT SERVICES APPLICATION
253-835-26
FEDERAL
• WAY
HL
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SF MF CO ME EL PL DE EN FP
SITE ADDRESS
f '�(�
e V 712-R
SUITE/UNIT # ZONING ASSESSOR'S TAX/PARCEL #
d a o- o s r
NAME OF PROJECT
(Tenant or Homeowner Name)
TYPE OF PERMIT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
GCAA V cAlr y
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ELECTRICAL ❑ ENGINEERING )(FIRE PREVENTION
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I certify under penalty of perjury that 1 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 t e city as a p of this application.
SIGNATURE: yy�� DATEr 0/14
PRINT NAME: I c6, v,\ R•%Cie l
Bulletin #100 -January 1, 2010 Page 1 of 4 k:\Handouts\Pennit Application
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NAME
PRIMARY PHONE
PROPERTY OWNER
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(�5.3 ) `�3c{ 03111-(
MAILING ADDRESS, CITY, STATE, ZIP
E-MAIL
CONTRACTOR ❑ APPLICANT PROJECT CONTACT
OWNER IS ALSO:
NAME
PRIMARY PHONE
�',r,:(-QS3)
833 - i;�-lss
MAILING ADDRESS, CITY, STATE, ZIP
1W6 Fi - ., . N ` k e _ L cac'.� :r_ LJ,L1 ; •i
FAX
(25 3 ) 13 5" - C5 / i 3
CONTRACTOR
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
Y�Z�SW i i�tc,Q la / 31 /to
ly..
NAME
PRIMARY PHONE
APPLICANT
�
MAILING ADDRESS, CITY, STATE, ZIP
FAX
PROJECT CONTACT
NAME
PRIMARY PHONE
(The individual to receive and
y1C1,3,e% R'. UC <
(vZS� 3) rat a s - 12,1
MAILING ADDRESS, CITY, STATE, ZIP
FAX
respond to all correspondence
concerning this application)
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( S'3)'J3S-- t` -
ALTERNATE CONTACT NAME:
PRIMARY PHONE
E-MAIL
Lxs
PROJECT FINANCING
NAME
OWNER -FINANCED
Required for projects with
MAILING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
value of $5, 000 or more
(RCW 19.27.095)
I certify under penalty of perjury that 1 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 t e city as a p of this application.
SIGNATURE: yy�� DATEr 0/14
PRINT NAME: I c6, v,\ R•%Cie l
Bulletin #100 -January 1, 2010 Page 1 of 4 k:\Handouts\Pennit Application
a