HomeMy WebLinkAbout15-102504CITY OF `
Federal Way
RE(WVED
MAY 26 2015
CITY OF FEDERAL WAY
CDS
PERMIT APPLICATION
PERMIT NUMBER -4i _ I—aA �f r% Y _ -E0
TARGET DATE
SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSO TAR/PARCEL # I - ol O O 7
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING AFIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
EMAIL
CITY
STATE
ZIP
NAME
PHONE
MAILING ADDRESS
EMAIL
CONTRACTOR
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CITY
STATE
ZIP
FAX
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WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
PRIMARY PHONE
MAILING ADDRESS
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EMAIL
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APPLICANT
CITY
STATE
ZIP
FAX
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NAME
PRIMARY PHONE
PROJECT CONTACT
MAILING ADDRESS
EMAIL
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
Required value of $5, 000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
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 city as apart of this application.
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SIGNATURE: DATE Z b ��-
PRINT NAME:
Bulletin # 100 - January 1, 2013 Page 1 of 3 k:\Handouts\Permit Application
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