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21-104039� 1 CITY OF Federal Way R F r€ r;u PERMIT APPLICATION 9/28 /2021 PERMIT CENTER + 33325 8", Avenue South + Federal Way, WA 98003-6325 rn v 01. F DF.P U. Wk. 253-835-2607 + FAX 253-835-2609 + permitcenterCcityoffederal%vay.com CONIAIUNITY t)F.v a.ornraT PERasrr NUMBER 21 _ 104039 CO ---- — TARGET DATE SITE ADDRESS �. °� 8 a �� SUITE/UNIT 7 I ( a PROJECT VALUATION ZONING ASSESSOR'S TAXIPARCEL $ TYPE OF PERMIT WBUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DGMOLITION ❑ ENGINEERING ❑ FIRE PREVrNTION NAi4xE OF PROJECT ! �d / AJ PROJECT DESCRIPTION O � � v R K Detailed description of work to I be incb.Lded on teas permit only iYALtE �/] PRIMARY PHONE � • �• 4 �J,, L� i �1 €i PROPERT OWNER MAILING ADDRESS E-MAIL 'f-„ w CITY STATE ZIP Ec2c(L-0(_ to q y-2-3 NAME L "IfI�►/ c °� z- � c PHONE EIA.ILING ADDRESS ire fe:0 e E-UAM CONTRACTOR Q L . /J FAX CITY STATE ZIP / I �n 1-"Q UEi 0 WA STATE CONTRACTOR'S LICENSE I EXPIRATION DATE NAME PRMLkRY PHONE 01pov E-MAIL MAILING ADDRESS aPPI,xcArrT CITY STATE ZIP Fpkx NAME PRIhL7RY PHONE PROJECT CONTACT _ D G-{ Al ffhe fndividutd to receive and MAILING ADDRESS P—ATAIL respond to au correspondence —acernang thLS applicaliors) CST! STATE 2IP FAX PROJECT FINANCING NAME OWNER -FINANCED Where value is $5,000 or more (RCW 19.27.095) bSAiLIh[Gl1I]ORFS3 C€TY, STATE, Z1P PHONE X eery fr under penalty of perjury that I am cite property Owen or author izad agent. o the praperly Owner. I certify that to the hest Of my knowledge, the informatt ' uUi' ned {n su art a this er-rrrit a iication iS trrlr and CGrrrct. I certify that I wilt compfy with Ott applicablE rj of CitFedcraf Way regulations pertaining to the work a [hari2ad by the issuance Of a permit. I understand that the issccance of this permit dOe5 Plot remove the Owner's responsibility for compliance with local, state, or federal laws rcgrtlating ror'-"Mctic rz ar en1dranrnentaI talus. 1 further agree to hold harmless the City of Federal Way as to any claim jinrtuding costs, _penses, and attomsV-%' fres incurred i the invrutagatian and dejensr• of such cfer[rr;J which mu &r rtradc b nnr crsnn, includin tits undersigned, and filed against the ell+ but only tvhcrrc suck plains arises out of the reliance of the city in luding its officers and e+rzPfO`%ces' upon the accuracy of ter ireformatran sr►ppI{pd !a tits city as a part of this application. SIGNATURE: PRTN NAME: I�_ltJ I� �ff,..,_ n t ©9/2,,,/7'2r