11-100253 0
1;10J1PC
Atcov'.-;-' _L_ 4__. - J I 2 _0_,2_ 6"
n� ' ,. ERMIT SF MF CO ME PL DE EN( )
Federal W ER, `i *I
COMMUNITY DEVELOPMENT SERVICE 001 P LI CATI O N
251835-2607•FAX 253� �+ ��a��i
www.Nnw- n C 4
S
SITE ADDRESS SUITE/UNIT•
3(51 s e+i1 Are S-w'
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL I
$ re ce 3 O 2 I O 4 _ el J q S.
TYPE OF PERMIT 0 BUILDING 0 PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGINEERING ]FIRE PREVENTION
NAME OF PROJECT ����
(Tenant Name/Homeowner Last Name) Re plc(ors/� AJ 16a.,6 e
Tn
PROJECT DESCRIPTION ,s-ra(1 new a 14+0..v►otil_ FIpe nihl.,. f. ,'1Tle".,
Detailed description of work to f h 4 CLO 4r►+i e •v►YI1 NEP�1 13 L,
be included on this permit only
NAME � TY'N PRIMARY PHONE
V V PROPERTY OWNER 6jvt61q
MAILING ADDRESS 3'S IT (,�.µ, Ave Si"-
E-MAIL
CITY c.e4.40e4 STATE ZIP
NAME WA Fire I� � 0 i ,, 3 • PHONE
.ol -7/it 79%
MAILING ADDRESS E-MAIL
CONTRACTOR 1 i Y4-I Tye Si SE Ste 6
CITY A VI w,C STATE
11272 3 ZIP FAX
I w 4%0-16.3-1 TSI
WA STATE CONTRACTOR'S LICENSE I EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE
WoLKV-P qq 6 OP `i r le i tl.
NAME Wolfe Five kote�fia► Shc. PHONE 360-79 if-7916
ADDRESS I
APPLICANT
i MAILING 'L I Tye St' SE Sje 6E-MAIL
CITY I`1 ohm �y/( ZIP STATE 91 L71 FAX Ioo-3'6! - 13S9
PROJECT CONTACT NAME PHONE
(The indivlr)��nl to receive and =` ivi��� ' i .-`i94-711G
respond to all correspondence MAILING ADDS (71J1( Si- E-MAIL �
concerning this application) �s } � Ste eff�L w"1 cefi✓r t,,,60-1•tow,
CITY IA'l o'1v Wit ZIP
34 -h 3- I ST9
ALTERNATE CONTACT NAME: PHONE E-MAIL
AilfTiOh Wore 319-7/if-inn,
PROJECT FINANCING NAME
0 OWNER-FINANCED
Required value of$5,000 or more
IRCW 19.27.0951 MAILING ADDRESS,CITY,STATE,ZIP PHONE
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 a part of this application.SIGNATURE: 97/4DATE I/ IOpp
/I4
PRINT NAME: SO '"14IAN
Bulletin#100-January 1,2011 Page 1 of 3 k:\Handouts\Permit Application