21-104981-Permit ApplicationCITY �. PERMIT APPLICATION
Federal
� �� r� PERMIT CENTER + 33325 8Lb Avenue South + Federal Way, a , WA 98003 6325
�y 253-835-2607 + PAX 253-835-2609 + ermitcente rich aifederalwa cam
PERUrr NUMBER? I _ $ _ _Sj - I � 2,0?,(
TAllr;z:�r DATE
SIT$ ADDRESS
BUTTS/UNCr f
PROJECT VALUATION
ZONING
ASSESSOR'S TAZIPARCZ{L 0
TYPE OF PERMT
PtUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLmON ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
•2,2D9r�t
u't( Inc a r�hi ki �Cka Lt� c-
PRQJ�SCT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
765�_.IVte i
PRIIKARY PHONE
4.58 `(Q., 6
PROPERTY OWNER
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MAMING ADDRESS
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!I CONTRACTOR
CITY
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STATE
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FAX
WA STATE CONiRAC rOWS LICENSE I
EXPIRATION DATE
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PRIYARP PHOIM
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APPLICANT
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PREKARY PHONE
PROJECT CONTACT
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KAILIRCIADDRR68SLJn9� 30" Ct f3e
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(The individual to receive and
I respond to all oorrespondence
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2M (`( 44, i _
PAX
concerning this application)
PROJECT FINANCING
NANAMEw�[
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D' OWNER-FINANCEb
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STATE ZIP
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PHONE
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l cert(fy under penalty of perjury that I am the property owner or authorised agent of the property owner. I cert(jy that to the best
of my knowledge, the information submitted in support of this permit application is true and correeL I cert(fy that I will comply with
aZZ applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. I understand that the
Issuance of this permit does not remove the owner's mapansibirity for compliance with local, state, or federal laws regulating
construction or environmental taws.
I further agree to hold harmless the City of Federal Way as to any claim (includirly costs, expenses, and attomeya' 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 arsuch clairn arises out of the reliance of the city, including ita officers and emprayeea, upon the accuracy Of the
information supplied to the city as a part of this application.
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BIGNATUPM: DATE
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Bulletin 4100 —February I9, 2020 Page I of 2 Bl•IandoutApermit Appji cation