21-105272CITY OF ''
Federal Way
PERMIT APPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
r:; '::''' :' ::`'•'• 253-835-2607 + FAX 253-835-2609 + permiLcenterigcityoffederalway.com
PERMIT NLr=R 9 tl _ 0 S~2 7 Z - "S ipff TARORT DATE
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VC /�+epIER4L WFQ wp ?003 j
PROJECT vALUATIox
ZONING
AS81t890R'8 TAX/PARCEL. Y
$
TYPE OF PERMIT
BUILDING PLUMBING N MECHANICAL ❑ DEMOLITION ❑ EN91NEERING ❑ FIRE PREVENTION
NAME OF PROJECT T
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PROJECT DESCRIPTION
Detaffed descnptwn of work to
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be included on this permit only
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NAME
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PRIMARY MQU
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PROPERTY OWNER
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MAMMQ ADDRZ"
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CONTRACTOR
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ZIP
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WA STATE CONTRACTORIS LICXNNE a
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EXPIRATION DATE
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NAME
PRIMARY PHONE
APPLICANT
MAa nra ADDREM
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CITY STATE ZIP
FAX
PROJECT" CONTACT
NAME
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PRIMARY PHONM:
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MAsrmla Arm>zs�a x 'Ts w3
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SMrj lE'Y
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
r
concerning this application)
PROJECT FINANCING
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OWNER -FINANCED
When value is A000 or more
MAVANG ADDRE98, CITY, STATE, ZIP
PHONE
(RCW ] 9.27 095)
I osrt(& under panalty of perjury that I am the prmpertly owner or authorised agent of the property owns: I omWfg that to the bed
of my knowledge, the igrormation submitted in aupport of this permit application is true and correct. I eer ft that I will comply with
all 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 rxmoee the owner'* reeponsibiiity for compliance with loco; state or federal Jaws rrgulaung
construction or environmental laws.
I jUrthsr agree to hold harmieas the City of Federal Way as to any claim (including coats, expense; and attorneys' fee* incurred in
the inwtdigation and defense of such ctaimj, which may be shade by any person, including the undersigned, and filed against the city,
but only whom such claim o the reliance of the ctty, including its ofJ'lears and employees, open the: accuracy of the
tilfar ux"an supp to the f this application.
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SIGNATURE: I PATE
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PRINT NA61E:
Bulletin # WO -February 19, 2020 Page 1 of 2 kAHandoutsTetmit Application
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