HomeMy WebLinkAbout15-104478 • •
CITY OF '�--- PERMIT APPLICAZION
Federal Way
0
CITY SEP 0 3 2015
PERMIT NUMBER _ 1 _ OF FEDERAL WAY
TARGET DATE CDS VYI`1 r
SITE ADDRESS SUITE/UNIT#J
S2,0 LA 32. ,..n A,VE.`> • ®
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL#
$ � , 253 2 \ c Lk 8 O - c, Z O
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING a FIRE PREVENTION
NAME OF PROJECT *PA C i F v S L v L +z ._ .
PROJECT DESCRIPTION
Detailed description of work to D SP Q,N k. L I 2 S OR— T.Z. WALLS (s- 1 L 11!G-5
be included on this permit only
NAME PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS E-MAIL
CITY STATE ZIP
NAME PHONE
PATo FTE --ri ' (`1 253 •Zast-i• 3—c-r,‘
MAILING ADDRESS E-MAIL
CONTRACTOR 2-r 0? 0.-7k AVE E
CITY STATE ZIP FAX
co A v'i, 9 8 4 Z-LI
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE#
FAs-r -IF Po 9q cFF 10 / 05 / r5 11-(11- 101488-00-
PRIMARY
1-(1l- 101488-00-PRIMARY PHONE
APPLICANT MAILING ADDRESS E-MAIL
CITY STATE ZIP FAX
NAME PRIMARY PHONE
PROJECT CONTACT M A7T C7/e EEA.1 2-5*3 -3-7 7. 'Z.272-
(The
2?2(The individual to receive and MAILING ADDRESS E-MAIL L ('
respond to all correspondence Z7 0.7 707-H4 VE mak To)e ecAriaTT;i'e.c o�
concerning this application) CITY STATE ZIP FAX
r/4- c,M4- ,'JA 9 8�-1 Z L/
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 taws.
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 a a part of this application.
SIGNATURE: DATE C/Z 7/
PRINT NAME: M A TT H f►^/ 61 ere-AA:
Bulletin#100-January 1,2013 Page 1 of 3 k:AHandouts\Permit Application
