20-101688-Building Permit Application-04-30-2020-V14ik
CITY OF
Federal Way
PERMIT NUMBER
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter�ticitvoffederaiway.com
TARGET DATE
SITE ADDRESS
_53 °.3 a4 ill, � ) ur1' 6,W lzdira.1.-1n/
SUITE/UNIT t
PROJECT VALUATION
$ k 000, q
ZONING ASSESSOR'S TAX/PARCEL M
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BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
TYPE OF PERMIT
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
NAME
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PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS
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NAME
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PHONE
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CONTRACTOR
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STATE
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FAX
WA STATE CONTRACTOR'S LICENSE 9
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE i
NAME � � (f � � 1 y, 0 /
PRIMARY PHONE
MAILING ADDRESS
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APPLICANT
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STATE
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NAME
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PROJECT CONTACT
MAILING ADDRESS
(The individual to receive and
respond to all correspondence
CITY
STATE
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FAX
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concerning this application)
PROJECT FINANCING
NAME
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OWNER -FINANCED
MAILING ADDRESS, ICITY, STATE, ZI
PHONE
When value is $5, 000 or more
(RCW 19.27095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. 1 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 paarrtt of this
/city dapplication.
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SIGNATURE: ,I w"'-"` �/` I/ V�"� C���' DATE
PRINT NAME: DQki % �L I (L
Bulletin #100 - January 29. 2016 Page 1 of 2 k:\Handouts\Permit Application