10-104689Federal °F� C .�E IV EL SPERIIPIIT
�w 1NIrY w»W5 V(CAPPLICATION
L -_Z_ _�2
SF MF CO ME PL DE EN FP
SITE ADDRELS I I y {"' 1✓K A}—
7 5,2[7 j�p�C E S �� r.J c� o�: �f Li
SUITE/UNIT #
0 f4
PROJECT VALUATION
ZONING
Asszssows TAIL P CEL #
7 a-Z a Q
-i 15. '_00
-
TYPE OF PERNIIT ❑ BUILDING El PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name/Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
KAME(
PRIMARY PHONE
PROPERTY OWNER
J
MAILING ADDRESS
E-MAIL
CITY
STATE
—
NAME / ff (
till �f•��ir�.-
PHONE (�- �-•.
.�l��U.? �
LrCONTRACTOR mG ADD S 7
i �
1 !e r-L tcf
CITY n
ST 1'
I�pl
ZIP �/y. I
FAX - 9S_91 - 2_?
WAIST TE CON17iACTOWS LICENSE #
EXPIIIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
L�
il. i�M-qn-
NAME �.
PRO
1
_
APPLICANT
i 1HG ADDRESS
MAIL
S
.t
C
S E
z IP
FAX /
r�
V C/l/ I
PROJECT CONTACT
1A t
PHONE
(The individual to receive and
1
`
ING ADDRESS I
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER -FINANCED
Required value of $5,000 or more
MADdNG ADDRESS, CITY. STATE, ZIP
PHONE
(RCW 19.27.095)
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 Pe city as apart of this ap 'catian.
}
SIGNATURE: CW DATE
U
PRINT NAME:
0-1-
Bulletin #100 -April 14, 2010 Page 1 of 3 k:\Handouts\Pemlit Application