12-100893CITY Of RECEim DPERMIT
Federal Way FEB 2 7 2u!
CO MMUMIYDEVELOPMEIVSERVICES ATIO N
253 - 835 -2607• FAX 253 -88'35 -2609 ' 1
cow. a der° w. T y O F F L
CDS
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SF MF CO ME PL DE EN FP
SITE ADDRESS
.3 ®i S a�- s I , rL SAY a
SUITEMNIT #
PROJECT VALUATION
$ a; c�y� y �a
ZONING
ASSESSOR'S TAR /PARCEL #
1 i - 5
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING Wfl'RE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
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&}�cuP 14E.4L1h FED -5PAf)Va TWM A // ,
PROJECT DESCRIPTION
Detailed description of work to
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1V 6-� S� t
be included on this permit only
PROPERTY OWNER
NAM B AC 5 R ViN�-- 6,9bvP t464&-)-y
"ONE
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MAILING ADDRESS
5-a i E fr AMA e;, IV 4L W�&i
o
CITY W i L
ZIP g G J
NAME
GQVV t GG1tVT ac r
ONE
S 2
MAD.DYG ADDRESS rue—Al C X��
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E'�L
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CONTRACTOR
p5�y�
CTIY,� `I / V i C--) `�
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ZIP 6;5
FAX 5 —231
WA STATE CONTRACTOR'S LICENSE #
E MP ATION DATE
FEDERAL WAY BUSINESS LICENSE #
NAME
60 A) E-)2 ill T
PRONE
" qW N TTL) CK Al" r .5. S0 /7z" / 00
MAZL : 4G50,06
APPLICANT
CPPY t
!-/
157
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FAX .
PROJECT CONTACT
NAME &_A E n�
/• `
(Ihe individual to receive and
respond to all correspondence
ADDRESS 7- T 61C �'C` vi
E-MAIL
concerning this application)
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BTAT
ZIP
S -'�5
CONTACT NAME:
WILL I
PHONE
:? — s
E -MAIL 4
KAP,4 , t�lt1
PROJECT FINANCING
NAME
OWNER- FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty gf perjury that 1 am the property owner or authorized agent of the property owner. 1 certVyy that to the best
gf my knowledge, the Wormation submitted in support of this permit application is true and correct. 1 cert(jy that I will comply with
all applicable City gf Federal Way regulations pertaining to the work authorised by the issuance of a permit. I understand that the
issuance gf this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I f urther agree to hold harmless the City gf Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense gf such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out gf the reliance gf the city, including its officers and employees, upon the accuracy gf the
information suppl4tot city as apart qFXhis a tion.
v DATE
SIGNATURE:
PRINT NAME:
Bulletin #100 - January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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