18-10450540k
CITY OF
Federal Way
PERMIT NUMBER ' }S
RECEIVED PERMIT APPLICATION
SEP 24 ZMOtMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
CITY OF FEDERAL WAY
COMMUNfTY DEVELOPMENT
1 0 q 6 o,S_ F,? A
— TARGET DATE
SITE ADDRESS
'�O'
SUITE/UNIT#
�-)'
R S e � Ao'0 Sw
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$ V 1 �o®
&�—
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
L S ✓t 'Q.� 1 3— 1
be included on this permit only
NAME
PRIMARY PHONE
Ar 4' 245
PROPERTY OWNER
�r e
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
NAME` -c_ \;k % N \ 1I `� Y A< C.�� V 6,-)
I�. ►LAZ
P HONE
5- L l ! 5--7 a k
MAILING ADDRESS DRESS
O Nz. ou 3 Dq
E-MAIL
i U
CONTRACTOR
CITY
De 5v�.�ItS
STATE
ZIP
`,�
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME � A - A � � � � U
4
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
APPLICANT •
CITY
STATE
ZIP
FAX
NAME -
�`C'�
PRIMARY PHONE
LJ t_1 S
PROJECT CONTACT
e •✓
Z S
MAILING ADDRESS
®J 0
E-MAIL
(The individual to receive and
respond to all correspondence
CI `
pe5 o� N�°�
STATE
UTA
ZIP
C7 4L�
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ 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.
1 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.
i
'-/J �
, LL
p< — 2 —(V
SIGNATURE: / !
DATE
'e 4<
I'A t LkvV
PRINT NAME:
Bulletin #100 - January 29, 2016 Page 1 of 2 kAHandoutsTermit Application
tum..,