12-104511DECEIVED*
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Federal WIT 0 2 2012 PERMIT
COMMU35 -260 DEVELOPMEW
253-83 -2609 SERVICES APPLI CATI O N
253 - 835 -2607• FAX 253 - 835 -26Q9
LVIvia hi0flMerUsrxo F FEDERAL WAY
CDS
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L
SF MF CO ME PL DE EN D
SITE ADDRESS 6- t } e4l . /3
SUITE/UNIT #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
I G_ T ( o --9 L 5
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING XFIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME -
PRIMARY PHONE
PROPERTY OWNER
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2Qk - fig, 75
MAILING ADD ,S�
E -MAIL
CITY
�l
STATE
ZIP
NAME
PHONE
Al Y ,V-f -- x ia'
MAILING ADDRE S
E -MAIL
CONTRACTOR
U -)AA
CITY
C / �tJ
STATE
lcJ
ZIP
C eJ
FAX
WA STATE CONTRACTOR'S LICENSE #
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
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NAME 6�/ //� j.
PHONE
MAILING ADDRESS
E-MAIL �1P,�+✓: S l,'T
APPLICANT
61-
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CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
g
MAILING ADDRESS
E -MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $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 o f the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied t the city p rt of this application.
SIGNATURE: DATE
PRINT NAME:%
Bulletin #100 -January 1, 2011 Page I of 3 k:AHandouts\Permit Application