Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
11-103587
CITY OF ` Federal Wa PERMIT COMMUNITY DEVELO� 253- 835 -2607• FAX -2609 APPLICATION www.dtuoffederalway.w 0 2 V 1 11 1 h I W PA`s is MF CO ME PL DE EN FP SITE ADDRESS C SUITE /UNIT# PROJECT VALUAyTION ZONING ASSESSOR'S TAR /PARCEL it TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING IRE PREVENTION NAME OF PROJECT (Tenant Name /Homeowner Last Name/ PROJECT DESCRIPTION Detailed description of work to Aoro a,f --eet be included on this permit only PROPERTY OWNER NAME 6r&M 6r& !�l''�- alk �V© PRIMARY PHONE q,�AING r ^ w &4t 4• EMAIL 6. CITY '!T—W J �� STATE l/>✓'/ / I ��f/ NAME 14 —tee s 5 PHONE z� -�� a MAILING ADDRESS _/J (/'�/ �i T' " ' " � —I JI 0& E -MAIL CONTRACTOR CIA h 8W� ZIP WA STATE CONTRACTOR'S LICENSE # 564 1 07" EXPIRATION DATE z FEDERAL WAY BUSINESS LICENSE # /9 87 -UWos =o NAME PHONE APPLICANT MAILING ADDRESS E -MAIL CITY STATE ZIP FAX PROJECT CONTACT (The inditndual to receive and respond to all correspondence concerning this application) NAME 11 / ^'`e I VC) PHONE Z53 -_2 OS MAILING ADDRESS 5 G-r'y1 '� E -MAIL cAe l VO Ld'M CITY STATE ZIP CV ALTER TE CO TACT E: �✓' e r PHONE 53- y8- E -MAIL v'P-✓' �� -L�-�i PROJECT FINANCING NAME OWNER - FINANCED Required ualue of $5,000 or more (RCW 19.27.095) 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. 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 a part of this application. SIGNATURE: DATE �/ Z PRINT NAME: Verne,.,- Bulletin #100 —April l4, 2010 Page l of 3 k:�Handouts\Permit Application l3L I