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HomeMy WebLinkAbout15-102005 .RECEIVED11111 CITY OF APR 27 2015 PERMIT APPLICATION Federal Way CITY OF EDERAL WAY CDS jjj tom.. PERMIT NUMBER 5 _ / O 0 ..c - III TARGET DATE - SITE ADDRESS SUITE/UNIT# oo 3Zu ` tL -ec�ev'?I (A) , CA)(Ni 9�aa.� PROJECT VALUATION LONING AS4S OR'S TAX/PARCEL# $ 0 q Z 1 0 q - qZ 0 J TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION NAME OF PROJECT Ut 11-Q. Rezu- TtVlah�l- 1m rc�'ev.1 ..D e- '411-.1 -Pit e „4evii, PROJECT DESCRIPTION Si r I Detailed description of work to 4,t t10c, 2[t {. 5)Id t _5V'70 Cov % -.30.eJ v/io l-i"f'L-2 h0/7• be included on this permit only NAME —1 Jtltl PRIMARY PHONE .___.. PROPERTY OWNER ��'L ( Villi Slilopi ` Cei�' �`�(� 1� �3 m L MAILING ADDRESS 7 c.�y I" E-MAIL I cC7 O (._-> �Z.C�?i`L _J I CITY STATE ZIP eClev'2I LO t c�©(1).3a NAME i PHONE W..230�UI 9,1-0 VI ,Mov'vl rv)G. (Z ),5zi - 3zsC MAILING AD ESSC,., E-MAIL t CONTRACTOR Z() 21) A:r90ff" Lk) —) ivi 11 @ 1AItem712-.i-i,eCN`' CITY 1' UU STATE ZIP FAX J WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE# W(NsN'_rA.L a6Z.G3 1 /O / l' To 00-IDIS Z4l -00-gt.- I NAME PRIMARY PHONE W0,44 i/7. \ \ (-au;; A-"(7.r v !/ 1' -i c • ( ro ) z Zr-3 '5'- APPLICANT MAILING AD s C EMAIL --CO-2,0 _.4 0 ,npor - V? 11 z/0...,•261/4,1,7) lttz,,07 .e''.•5 CITY N STATE ZIP FAX SeOf-t t GO fl C(�Si,7,`-f Czv6)32..Z - 7Z/a NAME51-0.0, 1-2,v,-1-- PRIMARY PHONE PROJECT CONTACT 1:241 �J (1Z,,'G, LI 34,-533 L'.. (The individual to receive and MAILING ADDRESS E-MAIL respond to all correspondence ZQ�O 4;,pc),, - W1 ,f�C .)2 w�'�y���HZ�z�s4, fi' concerning this application) CITY . , STATE ZIP FAX 5'7. f 'WA kt3y c-tary.).3zz ?z / 4 NAME PROJECT FINANCING ❑ OWNER-FINANCED Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE IRCW 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 arty 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 t'he 'y as a part of this apple eti,1,n. ,,.R ._.. SIGNATURE: ,: �..: DATE O /Z / Co t S~ PRINT NAME: 12✓l 4,4,w .r^ -- Bulletin#100—January 1,2013 Page 1 of 3 k:\Handouts\Permit Application