19-101020 (2)RECEIVE®
MAR 0 5 2019 PERMIT APPLICATION
CITY OF
�(�` rvrr�� � � p� A� PERMIT CENTER + 33325 8� Avenue South +Federal Way, WA 98003-6325
Federal Way cQur E 253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederal%vay.com
w
PERMIT NUMBER I 9 _ / ® 2,— C) - P � TARGET DATELtj
SUITE/UNIT #
[�SITFADDRESS
PROJECT VALUATION
$
ZONING ASSESSOR A7CIPARC 6 N 0 -
TYPE OF PERMIT
❑ BUILDING PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
aQ CA fa��u
l
l v 1n�r�
Rf S "� 11
W
rt f o j nr F Li_ . C` uA■ 1rr,.L - a'.-e
I cVJ 'a
NAME
PRIMARY PHONE
�
-E C LA +1 r
d,
LING ADDRESS
E-MAIL
PROPERTY OWNER
CIT'�r_
STATE
ZIP
C,Vu�
NAME SEC
PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
PITY
STA
Ch
ZIP
1
FAX
WA STATE CONTRACTOR'S L NSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
�L
NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
- -
NAME �.� �
PRIMARY PHO^N7E
PROJECT CONTACT
MAILING ADDRESS
E-MAIL
(The individual to receive and
respond to all correspondence
¢ '
STATE
ZIP
CJC�
FAX
concerning this application)
W
PROJECT FINANCING
NAME\ E C � ��
��
OWNER -FINANCED
When value is $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 CUM 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 flied 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 applicutia
r'
SIGNATURE:
DATE
PRINT NAME: Lj
Bulletin #100 - January 29, 2016 Page 1 of 2 k:\Handouts\Permit Application