21-104239RECEIVE®
114
CITY of OCT 0 8 2021
PERMIT APPLICATION
Federal Way c FEDERAL
WAY
DEVELOPMENT
�2 3 q — TARGET DATE
SUIT,eIUNIT 0
SITE ADDRESS
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL S
$ rrf--
TYPE OF PERMIT
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
Q BUILDING 81PLUMBING MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ nRE PREVENTION
'
WAA � D 'LiA S e c;fi��
_ -
NAME
MAII.IN�r ADDRESS - j ■
CITY STATE I ZIP
nLws I
MAILBAG ADDRESS
CONTRACTOR CITY STATE zrn
WA STATE CONTRACTOR'S LICENSE N EXPIRATION DATE
I 1
- NAME
G DRESS
APPLICANT
t 4 Z4,-'3
- � I I STATE ZIP
PROJECT CONTACT
The individual to receive and DRess
respond to all correspondence
concerning this application) STATE ZIP
PRIDfARY PHONE
E-SAIL
FAX
FEDERAL WAY BUSINESS LICENSE 6
' pH NE
E-NfAII.
FAX
ci-
PROJECT FINANCING
DOWNER -FINANCED
When value is $5,000 or more MAUING ADDRESS, TATE, ZIP PHONE
(RCW 19.27.095)
I certgy under penalty of perjury that I arm the property owner or authorized argent of the property owner. I certify that to the best
of my knowledge; the ir{ formation submitted in support of this permit application is true and correct I certV9 that I wilt comply with
all applicable City of Federal Way regulations pertaining to the work =dhori;ed by the issuance of a pm7nIt n�dtha t the
issz+'ce of this permit does not remove the owner's responsiNUty for compliance with local, state, f regulating
canstruction or enAronmental lawns.
Y further agree to hold harmless the City of Federal Way as to any claim (including costa, expe sM and attorneys' foes incurred in
the investigation and defense of such claw, which rrsRW 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, ineluding its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application.
w
Q.mPt;., ill nn—FP-hnvgry 2). 2016 Page 1 of 2
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