13-100148. PERMIT xPPLICATION
CITY OF -
Federal Way RECEIVED
`� PERMIT NUMBER 0 TARGET DATE JAN102013
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SITE ADDRESS
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL
$ .3 bop CrC/ci
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TYPE OF PERMIT
❑ BUILDING
❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION VENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
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PROPERTY OWNER
CONTRACTOR
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
NAME
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WAILINGADDRESS '
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CITT
NAME 6
MAH.DIG ADDRESS
CITY
WA STATE CONTRACTOR'S LICENSE #
NrrA�ME
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MAILING ADDRESS
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CITY I
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NAME
Pat U f i,C, b. Cf'
STATE I ZIP
STATE ZIP
EXPIRATION DATE
STATE I ZIP
i
SOF �c d r C-er N
MAH,ING ADDRESS r
CITY STATE ZIP
NAME
PROJECT FINANCING _�_ PC C1
Required value of$5,000 or more MAUA3iG ADDRESS, CITY, STATE,
(RCW 19.27.095) 33 3 e S 3 `fit' '-C 5
7 certify under penalty of perjury that 1 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 application.
SIGNATIIRE: , -DATE
PRINT NAME: j -
PRIMARY PHONE
-
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PHONE
E-MAH.
FAX
FEDERAL WAY BUSINESS LICENSE 8
PRIMARY PHONE
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E-MAIL
FAX
PRIMARY PHONE
E-MAIL
FAX
OWNER -FINANCED
'T PHONE
0
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Bulletin#100—January I, 2013 Page] of3 k:\Handouts\PermitApplication