HomeMy WebLinkAbout15-103741 =r� " � •
PERMIT ePPLICAT ON
Federal Way RECEIVE
C � 7-41, JUL 3 0 2015
PERMIT NUMBER _ l _
_ TARGET DATE CrrY OF FEDERAL.WAY
SITE ADDRESS 411W T#
PROJECT VALUATION co,�+ ZONING ASSESSOR'S TAX/PARCEL#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ElMECHANICAL ElDEMOLITION ElENGINEERING FIRE PREVENTION
NAME OF PROJECT ?C 1 &Np- e-5 l Q AA ` `2\ \ \" OQO
L. c?-1-)e yk,cctoe, 5
PROJECT DESCRIPTION '-,
Detailed description of work to W(LAX y1Q_,L3 1\ccLv-Q , L1 1CD 2.& S S 1 rt c 3y
be included on this permit only
NAME c�1 PRIMARY PHONE
PROPERTY OWNER yj cog% ltd' l - uto,t\._. C ,32,tA
MAILING ADDRESS' E-MAIL
CITY i STATE ZIPpp +�
NAME-`C�\C.`V �.C.., '1 O C'J ( �� P 1 C, 1'0 J-r' c `-6-3
MAILING ADDRESS E-MAIL
9
CONTRACTOR 0 f20•0- '%Z
CITY STATE ZIP FAX
YVl ,X\ C_c-e-eA . w 2 `)'%C;47s=.2
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
.c,s464,‘0 0_, 11 i 9; / 1 '7
NAME ;� PRIMARY PHONE
C,\1�v1 c 1 J 0,, .1�� 2C) o -"1 3 ' 2_c-6
APPLICANT MAILING ADD E-MAIL
PCS 1 Cs (AC:v.3 = (. �10(.1,.(3iz
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT 4czAfh t c \) n
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
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 19.27.095)
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 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 c' as a art o this application.
i l
SIGNATURE: DATE 7/ z(6/ol
l ,
1
PRINT NAME: 0111
