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HomeMy WebLinkAbout15-103240 CITY OF ,. • PERMOE IPLICATION Federal Way JUL 0 6 2015 / } /"� pCOFFEDERALWA(PERMITNUMBER / S _ _ TADRGET DATE SITE ADDRESS '� ` SUITE/UNIT# 3 (1 C13 y tJcyGgCr'v5e7z Liny S �ct)r- � w14-y PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL# .00 2. 2 / 0 - 9 p 3 1 ge AA TYPE OF PERMIT ❑ BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING %FIRE PREVENTION I NAME OF PROJECT (-^)(. J/iS/U,t) F/Czi(L PROJECT DESCRIPTION l tis 77 L NL-tJ ,t/dT/'/C4'7-,0) - �e(7/C e'S �p Detailed description of work to VC/0 CATC- e-)(I C-r-7/1/C, ..74-,--I.CC S be included on this permit only NAME PRIMARY PHONE PROPERTY OWNER (�^�� LZ, Vi Stc3- /'VC'VC- MAILING ADDRESS E-MAIL -3y(63`/ lei✓/ 1Q71-A-C 67-- cal/ S CITY STATE ZIP NAME PHONE k tg-z 6).S7-<'7,15 (EST l AiC 'LS- —‹b 33— ruses MAILING ADDRESS E-MAIL CONTRACTOR • ' C-IZ 'AGCS {CS) &J Sv\TF- 'C— CITY STATE ZIP FAX WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# F/, i( C,5s's'-L-Al (e, A, / ,s' /?-‘67'0410/((-00 py-00-VL NAME PRIMARY PHONE /V4-77- (3,444,,,,m,4 " APPLICANT MAILING ADDRESS E-MAIL CITY STATE ZIP FAX NAMEIMARY PHONE PROJECT CONTACT /9,'Ij- G',4a�/ "S'7-9.c/--6. 5 (The individual to receive and MAILING ADDRESS E-MAIL respond to all correspondence l'f4-/ P 1:77.4.-c.,--5771- 7.54-,07:e".7 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 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 suc lain) which may be made by any person, including the undersigned, and filed against the city, but only where such claim arise of the reliance of the city, including its officers and employees, upon the accuracy of the information supplied to the city part of this application. SIGNATURE: /' ,% DATE f i/L i /f PRINT NAME: (M/L77-- (4/%0-4.14..../ Bulletin#100-January 1,2013 Page 1 of 3 k;AHandouts\Permit Application