23-101750-PermitApplication-4-10-23CITY OF 7..,,_�_ _ � PERMIT APPLICATION
PER
Federal Way MIT CENTER + 33325 81^ Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcente a)cityoffederalway.com
PERMIT NUMI3ER G 2 _ 1 0 —1 G 5 _ C F TARGET DATE
SITE ADDRESS
SUITE/UNIT #
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PROJECTVALUATION
ZONING
ASSESSOR'S TAR/PARCEL 8
$ / 0/ 000. oD
— — — — — —
TYPE OF PERMIT
,BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
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PROJECT DESCRIPTION
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Detailed description of work to
-
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be included on this permit only
NAME
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PRIMARY PHONE
253 --7., l4 3"1
PROPERTY OWNER
MAILING AD RESS
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E-MAIL
CITY v7 ` I
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ZIP
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MAILING ADD
E-MAI A
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CONTRACTOR0�6
CITY
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ZIP
FAX L'
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WA STATE CONTRACTOR'S LICENSE Y
EXPIRATION DATE
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NAME
PRIMARY PHONE
APPLICANT
MAILING ADDRESS
E-MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAM 1 ,,� ,,� ^ f
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PRI►MAAR,Y PHONE �/
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E-MAIL �/��
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(The individual to receive and
respond to all correspondence
CITY _ /
Y
STA
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zIP�
FAX
concerning this application)
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 1927.095)
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 the city as apart of this application.
SIGNATURE: / DATE 3/23/23
PRINT NAME: f /Ell (>}},tyn�1-
Bulletin #100 - February 19, 2020 Page I of 2 k \HandoutslPermit Application