12-102264C -�
�,r� �EIVED PERMIT
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COMMUNITY
D E VELOP M2 �253 - 835 -2607d 3 -26#
2 202 APPLICATION
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CITY OF FEDERAL WAY
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SF MF CO ME PL DE EN P
SITE ADDRESS
SUITE /UNIT #
Q PROJECT VALUATION '
ZONING
ASSESSOR'S TAX /PARCEL #
TYPE OF PERMIT
❑ BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING IRE 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
NAME `
PRIMARY PHONE
PROPERTY OWNER
MAILING ADD
E -MAIL
CITY
I S A
ZIP
NAMEl�� VZ L f
PHONE
MAILING ADD 2ag d el
CONTRACTOR
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WA STATE CONTRACTOR'S LICENSE #
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XPIRATION DATE
/ /
FEDE WAY BUSINESS LICENSE #
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_17220
NAME
PHONE
APPLICANT
MAILING ADDRESS
E -MAIL
CITY
STATE
ZIP
FAX
PROJECT CONTACT
NAME
PHONE
(The individual to receive and
MAILING ADDRESS
E -MAH,
respond to all correspondence
concerning this application)
CITY
ST E
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
OWNER - FINANCED
Required value of $5,000 or more
(RCW 19.27.0951
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
SIGNATURE: DATE 2
C / r
PRINT NAME: L/
Bulletin #100 —January 1, 2011 Page 1 of 3 k:\Handouts\Permit Application
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