10-104185Federal Way
CrAWIrNITY DEVELOPMENT SERVICES
2.53. 835.2607• FAX 253 -835 -2609
`PERMIT
APPLICATION
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10 MF CO ME PL DE E FP
RECEIVED
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SITE ADDRESS SUITE /UNIT-W-
1010 S 3 �,'�" Sf CITY OF FED RALIM&
PROJECT VALUATIO/N� %�
ZONING
ASSESSOR'S TAX /PARCEL # n %�
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1 ,2 � 5 �L SL
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING MECHANICAL
❑ DEMOLITION ❑ ENGINEERING FIRE PREVENTION
(Tenant Name OF PROJECT erame)
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PROJECT DESCRIPTION
Detailed description of work to
be included on this permit only
NAME
PRIMARY PHONE
PROPERTY OWNER
MAILING / /v 3
E -KAIL
CITY
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ZIP
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E-MAIL - �1
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CONTRACTOR
CrrY
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FAX 3 0 3 6,
WA STATE CO CTOWS LICEN #
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=PIRATION DATE
FEDERAL WAY BUSINESS LICENSE #
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NAME
SA-rn. a S Grp
PHONE
MAILING ADDRESS
E-MAIL
APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
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(The individual to receive andC
respond to all correspondence
MAIIdNG ADDRESS /
EMAIL
concerning this application)
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CITY
STATE
ZIP
FAX
ALTERNATE CONTA NAME:.
i-
PHONE
EMAIL
n Pet 1 oV-
253 (,93, t
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5, 000 or more
(RCW 19.27.095)
MAILING AIWRESS, 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: �y/ifr'� DATE
PRINT NAME: 1 LD'✓'`e. ( P (J 1—L rkt- i; S x
Bulletin #100 - April 14, 2010 Page 1 of 3 k:\Handouts\Permit Application
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