22-101474RECEive
� DPERMIT APPLICATION
CITY OF APR 0 4 2022
Federal Way
Cray OF F�r�r~ WAY
+ L�NrTY SKIS PM..
PEIZMiT NUMBER L/` j _ _L O
TARGET DATE
SITE ADDRESS SUITE/UNIT #
2 0 1 3 q 4" 5. 50 F�oegx� V V,�A $oZ�
PROJECT VALUATION ZONING ASSESSOR' TAX/PARCEL #
$
TYPE OF PERMIT lal BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT �A w S Ec-n o rJ UJA P FW Z-U
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
PROPERTY OWNER
CONTRACTOR
APPLICANT
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
PROJECT FINANCING
When value is $5, 000 or more
(RCW 19.27.095)
NAME
MAILING ADDRESS _
PRIMARY PHONE
21D6_919 — IBC
�J'(a
CITY STATE ZIP � 0
errs. LJ D ll
NAME — — PHONE
MAILING ADDRESS E-MAIL
CITY STATE ZIP I FAX
WA STATE CONTRACTOR'S LICENSE #
NAME -1 n
EXPIRATION DATE 1 FEDERAL WAY BUSINESS LICENSE #
MAILING ADDRESS
CITY S q ZIP /J &2-3
MAILING ADDRESS
CITY I STATE ZIP
NAME
MAILING ADDRESS, CITY, STATE, ZIP
PRIMARY PHONE
E-MAIL
FAX
PRIMARY PHONE
E-MAIL
FAX
❑ OWNER -FINANCED
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 aris out of the nee of the city, including its officers and employees, upon the accuracy of the
information supplied to the ci as part a is a licutian. ,{
SIGNATURE: DATE 4( A'L-
PRINT NAME: U` N F'�,fj ArYC
Bulletin # 100 —February 22, 2016 Page 1 of 2 k:\Handouts\Permit Application