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HomeMy WebLinkAbout15-106508A RECOD CIN OF Federal Way DEC 2 3 2015 CIN OF FEDERAL WAY PERMIT NUMBER _ l 0 COS S 0 PERMIT'WPPLICATION FTARGET DATE SITE ADDRESS SUITE/UNIT # 3�`w'4- 2i 01 Ave- w PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL # TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING U i'IRE PREVENTION NAME OF PROJECT PROJECT DESCRIPTION �� ��i/�k,, Detailed description of work to d Ale7unen N V_ t S be included on this permit only PROPERTY OWNER NAME k! 6A 9 `�, PRIMARY PHONE MAILING ADDF43SS I E-MAIL CITY STATE ZIP NAME 1 / N PHONE y L MAILING ADDRESS E-MAIL CONTRACTOR too ` ox k)jVi'QyeL4 AO CITY A( f-rr STATE wA ZIP 9'?o FAX WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE # NAME// �/;'1e PRIMARY PHONE c G hV APPLICANT MAILING ADDRESS E-MAIL CITY STATE ZIP FAX NAME^^ A S k) 61' e A PRIMARY PHONE PROJECT CONTACT P MAILING ADDRESS E-MAIL (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 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 city , part of this appli tion. SIGNATURE: J DATE /Z 3 — I ` / PRINT NAME: ' G' Bulletin # 100 — January 1, 2013 Page] of 3 k:\Handouts\Permit Application ME