21-103311RECEIVED PERMIT APPLICATION
CITY OF �1 AUG 0 6 2021
Federal Way PERMIT CENTER + 33325 8th Avenue South +Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
PERMIT NUMBER °�
— TARGET DATE
SITE ADDRESS SUITE/UNIT #
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL # -
TYPE OF PERMIT
BUILDING ElPLUMBING El MECHANICAL ❑DEMOLITION El ENGINEERING El FIRE PREVENTION
NAME OF PROJECT
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
CONTRACTOR
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
When value is $5,000 or more
(RCW 19.27.095)
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NAME PRIMARY PHONE
MAILING ADDRESS E-MAIL
VTY STATE ZIP
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NAME PHONE
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MAILING ADDRESS E-MAIL
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CITY - STATE I ZIP FAX
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WA STATE CONTRACTOR'S LICENSE # I EXPIRATION DATE I UBI #
NAME PRIMARY PHONE
MAILING ADDRESS �. �� w C.
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FAX
N E PRIMARY PHONE
MAILING ADDRESP O E-MAIL
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NAME
El---OWNER-FINANCED
MAILING MAILING ADDRB CITY, STATE, IP PHONE
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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 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 city as apart of this_9pp(ication.
SIGNATURE:
PRINT NAME: ZV -
DATE ?::> -LQ - �2- 1
Bulletin #100 - February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application