22-100872-Permit Application 2-03-23-2022-V141k
CITY OF
Federal Way
PERMIT NUMBER
PERMIT APPLICATION
PERMIT CENTER + 33325 811, Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter@cityoffederalway.com
TARGET DATE
SITE ADDRESS
SUITE/UNIT #
8q3 3 �Z4-A ZCfA ge90z
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PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
TYPE OF PERMIT
BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
!"
PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
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NAME V
PRIMARY PHONE
PROPERTY OWNER
MAILING ADDRESS _
E-MAIL
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CI Y
STATE
ZIP
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PHONE
360-moo
MAILIN ADDRESS
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E-MAIL//'
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CONTRACTOR
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STAB
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FAX
WA STATE CONTRACTOR'S LICENSE #
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EXPIRATION DATE
OZZ03122
UBI #
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PRIMARY PHONE [� _
- 2` (S�
MAILING ADDRES
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E-MAIL
APPLICANT
CITY
i�
STATE
ZIP
6,yoz-
FAX
PROJECT CONTACT
NAME
a
PRIMARY PHONE
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MAILING ADDRE
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E-MAIL L�4(.
%iuW.n
(The individual to receive and
respond to all correspondence
CITY
STATE
ZIP
FAX
concerning this application)
PROJECT FINANCING
NAME
r-�
®a OWNER -FINANCED
When value is $5,000 or more
MAILING 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. 1 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: l� ra DATE 02 /C%t 240? Z
PRINT NAME:
Bulletin #100 -February 19, 2020 Page I of 2 k:AHandouts\Permit Application
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY?
WATER PURVEYOR
SEVIEER PPUQRVEYOR Q�
VALUE OF EMSTING IMPROVEMENTS
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EXISTING/PREVIOUS USE
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LOT SIZE (In Square Feet)
EXISTING FIRE SPRINKLER SYSTEM?
V'Yes ❑ No
PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes W No
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Bulletin #100 — February 19, 2020 Page 2 of 2 k:\Handouts\Permit Application