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12-102213« ;ayo - RECEIVED �'ERMIT St'�'iviF CO ME PL DE ENCP) Federal Way Y 1 z 201APPLI CATI O N COMAfUN1TY' DEVELOPMENT SER4� 253- 835 -2607• FAX 253 - 835 -26 CITY OF FEDERAL ftf me SITE ADDRESS 3 �2� C�,�Ewa= -� VSjva. S SUITE /UNIT B PROJECT VALUATION $ ©g ZONING ASSESSOR'S TAR /PARCEL n 9 2 1 A_ TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING1 FIRE PREVENTION NAME OF PROJECT (Tenant Name /Homeowner Last Name) l F C,\ f�l ��je (�. y� e 5 (� U r v- kA PROJECT DESCRIPTION r ' �� l I N W �� ✓�� a Z i/1 O- ✓� x ►� { i� L Q , 57s Detailed description of work to be included on this permit only PROPERTY OWNER NAME ry,m �\+ejr- AoA n,,,0 - PRIMARY PHONE p 79$ MAILING ADDR S F� goY_ 99:7 j a E -MAIL CITY L�Ke IvOv STATE. W ZIP NAME PHONE 1 3 - S 31- -71 S MAILING ADDRESS L� h 5 T `AVM E-MAIL L 1'� ©i'h( �eLUt COMco/k , CONTRACTOR CITY Q �, 0 ✓�A. 01 STATE t%,� qq Q yp ZIP J � I� I � F�� 3 r 3'3 ( -1169 WA STATE CONTRACTOR'S LICENSE A AukpMCC - WfN—o �- EXPIRATION DATE FEDERAL WAY BUSINESS LICENSE M 20- 39 go 8L NAME PHONE APPLICANT MAILING ADDRESS E -MAIL CITY STATE ZIP FAX PROJECT CONTACT (The individual to receive and NAME PHONE MAILING ADDRESS E -MAIL respond to all correspondence concerning this application) CITY STATE ZIP FAX ALTERNATE CONTACT NAME: h PHONE r - - -76c,) E -MAIL PROJECT FINANCING NAME El 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. 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. 1 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: � " ` DATE PRINT NAME: !- m U Sri Bulletin #100 — January 1, 2011 Page I of 3 k: \Handouts \Permit Application 'o Ih