21-101124-permit application-3-26-21-v1I PERMIT APPLICATION
CITY OF V:k�
PERMIT CENTER + 33325 8� Avenue South +Federal Way, WA 98003-6325
Federal Way253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
PERMIT NUMBER
.�... - ..-TARGET DATE
SITE ADDRESS SUITE(UNIT #
e- R �\0 , _ ( FBI Cr � i c 'VOA
PROJECT VALUATION ZONING ASSESSOR'S TAXIPARCEL'#
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION El ENGINEERING El FIRE PREVENTION
PROJECTNAME OF PROJECT i
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Detailed description of work to
be included on this permit only
_. ..NAME PHONE
PROPERTY OWNER MAILING ADD ss E-MAIL
3- 3 � �
CITY,. a STATE ZIP
_. NAME -.... PHONE
MAILING ADDRESS _... ...E-MAIL
CONTRACTOR
-CITY... STATE ..ZIP _. ..FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE UBI #
_.. VAMP, PRIMARYARONE
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APPLICANT MAILING ADDREss. E-MAIL
it'' °. tit' cN
CITY STATE ZIP ww FAX °
g PRIMARY PHONE
NAME
PROJECT CONTACT �Y Y fit" V -31
(The individual to receive and .MAILING ADDRESS E-MAIL
respond to all correspondence c vvk!
concerning this application) :CITY STATE ZIP FAX
NAME
PROJECT FINANCING
3 O ER -FINANCED
When value is $5, 000 or more MAILING ADDRESS, CITY, STATE, ZIP PHONE '...
(RCW 19.27.095)
I
I certify Wender penalty of perjury that I not 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 pewit 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 Iocal, 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 undersignad, 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.
SIGNATURE: � c ATE
PRINT NAME: o ern
Bulletin #100 -February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application