10-102999 (2)ckrroser ,Way PERMIT �� S'F 1''
FedCO ME PL DE EN FP
c25-1-W5,2nf7-FM.253-rslaRs5 2010APPLICATION
253.835.2l3U7• FA7(25a•H3S-
E-EDERAL WAY
SITE AI] SUITE/UNIT #
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT Y-BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to Y be included on this permit only
PROPERTY OWNER
CONTRACTOR
APPLICANT
PROJECT CONTACT NAME
(The individual to receive and
respond to all correspondence
concerning this application) [;
PROJECT FINANCING
Required value of $5,000 or more
(RCW 19.27.095)
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ADDRESS
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ZIP ��r
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re ZIP q'K I U
..#} EXPIRATION DATE
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STATE
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MAILINGjr�AD[�DRES�S,�-CCI�T'�YSTATE,
l, 11TAAATE, ZIP
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ZIP IG
PHONE
PRIMARY PHONE
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PHONE
FEDERAL WAY BUSINESS LICENSE #
PHONE
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PHONE 2OW `7IS �WC]3
E-MAIL
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FAX
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OWNER-FLNAHCBD K
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 oat of the reliance f the city, including its gaicers and employees, upon the accuracy of the
information supplied to the city as a part of this application,
-I
SIGNATURE: DATE 1
PRINT NAME: '
Bulletin #100 - April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application