22-100121RECEIVED
JAN 1
[{Ty Or _ � 2022
Federal Way CITY OF FEDERAL WAY
COMMLINfTY DEVELOPMENT
PERMIT APPLICATION
PERMIT CENTER + 33325 8th Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffeder8,lway.com
PERMIT NUMBER �( — / ^® jl rj / — TARGET DATE
SITE ADDRESS V Jf —,F— SUITE/UNIT #
PROJECT VALUATION ZONING ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT ; I i �/ r )-3 1 '--- k e V1 , / l ?- fl c
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
of a Uw`0.9rrA . x4A,a(4c.1
PROPERTY OWNER
NAME
PRIMARY PHONE
MAILING ADDRESS
E-MAIL
CITY
13�11
STATE
l,vl�
ZIP
CL
_
NAME
Q X— C
; c-^ rVin,
PHONE
Z-T3 - "7 rci - 'T 3 (.
MAILE-MAIL
LIING ADDRESS l 1
a S 16 3 }� Skrae_T
A%
E-MA
c —
CONTRACTOR
CITY
Tc. to
STATE
1 W A
ZIP
C LZ
FAX
WA STATE CONTRACTOR'S LICENSE #
Rl P
EXPIRATION DATE
►Z i z°mar
UBI #
6 OL4 - 3- Ll '7
NAME
is
PRIMARY PHONE
2g-;2, 3ZS`- coHv
MAILING ADDRESS
3 tc700 1 ?,
Sw
E-MAIL
APPLICANT
CITY
rrd .L w
STATE
WON
ZIP
�LuZ
FAX
NAME
3
_
PROJECT CONTACT
PRIMARY PHONE
OC`) v
MAILING ADDRESS
Y (,0%0 0
E-MAIL
(The individual to receive and
respond to all correspondence
CITY
aj-,.0.1
STATE
ZIP
atvZ3
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW I9 27.095)
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. 1 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.
SIGNATURE: {� rl' DATE �~ I
PRINT NAME:
Bulletin #100 — February 19, 2020 Page 1 of 2 kA-landoutsTermit Application