12-103822PERMIT S F CO ME PL DE EN FP
CITY of
Federal way��,�vEp
CoMMn�NInDEI- FAX2FN APPLICATION
253- 835 -2607• FAX 253.8 S- 609
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SITE ADDRESS
SUITE /UNIT #
QF FEE
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PROJECT VALUATION
ZONING
ASSESSOR'S TAR /PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING f FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name )
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PROJECT DESCRIPTION
Detailed description of work to
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be included on this permit only
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NAME
PRIMARY PHONE
PROPERTY OWNER
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MAILING ADDRESS
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CITY
STATE I
ZIP
NAME l
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PHONE
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LING ADDRESS -71-7/
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CONTRACTOR
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STATE
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WA STATE CONTRACTOR'S LICENSE #
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EXPIRATION DATE
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FEDERAL WAY BUSINESS LICENSE #
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NAME ``
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PHONE
MAILING ADDRESS
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APPLICANT
CITY
STATE
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
concerning this application)
NAME 5,c 6 Ida
PHONE
MAILING ADDRESS � p
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CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E -MAIL
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 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 O �/
PRINT NAME: lO �tm e / G ezleoew S
Bulletin #100 - January 1, 2011 Page] of 3 kAl-landouts \Permit Application
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