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car or --- PERMIT APPLI541
Federal Way
SEP 282015
PERMIT NUMBER 5 _ t o m -l 010 _ T CITY OF FEDERAL WAY
TARGET DATE
CDS
SITE ADDRESS SUITE/UNIT#
Sc 7 A/c_ TEb Sc 5 ) so/
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ \ Safi el 5 _ 0 6 2- 0
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AT FIRE PREVENTION
NAME OF PROJECT VCg_af.a 5\-k Z..(—
PROJECT DESCRIPTION �"CLo 67. Sin")Co e�VT'-\ LATlot�l �C- VIL( .
Detailed description of work to -� \! STS LL- ),J E //J kT l A VT I t.- a V 1 C.le'S
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
•
CITY STATE ZIP
NAME PHONE
C I(LE- SyS S wrsr /JL z:“-435—/Z-'fSS
MAILING ADDRESS E-MAIL
CONTRACTOR 7-954.o (F as'-1 Mott (LD � 5 V \TE^—(-.
CITY STATE ZIP FAX
"1 WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
(-IiLE sLA cbSS(-.v / l(7 / ► 1 Icl-v7-46 so l f -9556.--BL
NAME PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
" CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT PAPfT C..3-CL.L._r t 1-'6-3- 5 -(,4g5 c.6
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence 6i i M C
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING 0 OWNER-FINANCED
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27095)
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 cit a part of this application. /
SIGNATURE: "/14)77— ///� DATE �j/ 5/�C
PRINT NAME: (._A2�wi,4../
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application
