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CITY orA PERMIT PPL ATION D ��
` Federal Wa y
ECEIVE ��
, NOV 18 2015
PERMIT NUMBER —
_ TARGET DATE m
CDS
rilliriMMII"
SUITE/UNIT#
t ° a -5 a°Pt MI*g k e hit 12
PROJECT VALUATI. ZONING 1 ASSESS G ¢TRP AR #� 2 4 0 _ C) C ( C)
TYPE Olr PERMIT ❑BUILDING ❑PLUMBING ❑ MECHANICAL ❑DEMOLITION ❑ENGINEERING ;VIRE PREVENTION
NAME OF PROJECT Oo.\S
PROJECT DESCRIPTION implyAw L
Detailed description of work to MILZPAIIIA ,,, ■LillhTMMUIMIIIIIIIIIIIIIIIIIIIIII.M1
be included on this permit only
NAME PRIMARY PHONE
�
. rx c. yY cL\\
PROPERTY OWNER G ADD E-MAIL
CITY STAT; ZIP
ma PL° ■k PHONE
NCLEEVk9 r .'V\ -e- l C�� l /-12G'4S1`
-7(QCo \
. NG AD,-'== E-MAIL •
CONTRACTOR f� /` ! - V U.-)f\7 (i1rY\
rimiiii
IA fr ' h.. MI i 4 0 k
WA STATE CONTRACTOR'S LICENSE It H..''RATION DATE FEDERAL WAY BUSINESS LICENSE#
i I' / % /
--- - — - - — -- --PRIMARY PHONE
APPLICANT
MAILII4G ADDRESS E-MAIL
CITY STATE ZIP FAX
E PRIMARY PHONE
PROJECT CONTACT - ,i A AIL' J�'�' 411,1111110 �r`r
(The individual to receive and `
ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME
PROJECT FINANCING ❑ 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 authorised 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 authorised 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 a part of this application.
SIGNATURE:. /L� ✓ L'L DATE 1\A-7/ f
PRINT NAME: Al Aka
Bulletin#100—October 26,2015 Page 1 of 3 k:\Handouts\Permit Application
