HomeMy WebLinkAbout15-100744 rirtbri • RPCEIV�D PERMIT IPPLICATION
' Federal Way FEB 17 2015
CITY OF FEDER/A/L WAY
PERMIT NUMBER 1 5- i C) n 11 Y _
' l ' p TARGET DATE
SITE ADDRESS SUITE/UNIT#
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PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL if
$ 260.0 0 CA n'1 \ 0 2\ - °'l 0 3
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL 0 DEMOLITION 0 ENGINEERING DIRE PREVENTION
NAME OF PROJECT \ W'j%
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PROJECT DESCRIPTION
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Detailed description of work to
be included on this permit only
— — -- -- —
NAME PRIMARY PHONE
PROPERTY OWNER Sr�r � Q_ cc�'�`
_(-vac-- ACz - -e-o( 1 1
MAILING ADDRESS
l t Q E-MAIL
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C Y STATE ZIP
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NA �rIcrc Cr` )c PHONE
MAILINIGADDRESS Ll E-MAIL
CONTRACTOR \-11) Acc Ng• - 1
CITY STATE Z FAX I
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WA STATE C NTRACTOR'S LICENSE M EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE k I
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NA T PRIMARY PHONE
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APPLICANT MAILING ADDRESS
RESS �y E-MAIL —
ITT STATE ZIIPPQ�'� FAX I
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NAME PRIMARY PHONE I
PROJECT CONTACT ,----
(The individual to receive and MAILING ADDRESS E-MAIL
respond to all correspondence
concerning this application) CITY STATE ZIP FAX
NAME - - --
PROJECT FINANCING ❑ OWNER-FINANCED
I
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 I
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 I
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 j
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. I
SIGNATURE J DATE C5 I n CJI)
PRINT NAME: _ i ` t , .4 •
Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application
