21-103515AIIIN�,
CITY OF ---
Federal Way
PERMIT NUMBER 1;� \ _
RECEIVE®
PERMIT APPLICATION
AUG 19 2021
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
CITY OF FEDERAL WAY 253-835-2607 + FAX 253-835-2609 + permiteeriter(ruci.tyoffederalwgy.cosxi
COMMUNITY DEVELOPMENT
o 3 5- j TARGET DATE
SITE ADDRESS
SUITE/UNIT #
PROJECT VALUATIOINN
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
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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 PHONjE
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PROPERTY OWNER
MAILING ADDRESS -;;;]]]L���
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/E-MAIL
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STATE
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�ZIP I ✓
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NAME
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iM�I i ADDRESS
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AIL
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CONTRACTOR
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WA STATE CONTRAC,TTO�-R'S yLIIC']E,NSE I
EXPIRATION DATE
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NAME l` ry
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PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY STATE
ZIP
FAX
PROJECT CONTACT
NAME{ �kl
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PM PH<)VE
(The individual to receive and
respond to all correspondence�L?1�"
LING ADDRE r
E-MAIL
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STATE ZIP !
FAX
! 'concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When Value is $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
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 casts, expenses, and attorneys' fees incurred in
the investigation and defense of such clainq, which may be made by any person, including the undersigned, and filed against the city,
but only where such Chaim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a pjxrt of this application,
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SIGNATURE: & DATE
PRINT NAME: LlY
Bulletin n100 — February 19, 2020 Page 1 of 2 UHandoutsTermit Application